Occupational Therapy Evaluation (CPT code 97003) and Occupational Therapy Re-evaluation (CPT code 97004)
Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time.
1. The initial examination has the following components:
a. The patient history to include prior level of function should be assessed using a method which allows for objective measurement of function and comparison of successive measurements.
b. Relevant systems review, including medications, if known
c. Tests and measures should be performed using a method which allows for comparison of successive measurements,
d. Current functional status (abilities and deficits), and
e. Evaluation of patient’s, physician’s and as appropriate the caregiver’s goals
2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient’s overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Occupational therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment. While a patient’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.
3. Initial evaluations or reevaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient’s condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.
4. Reevaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient’s condition or functional status that was not anticipated in the plan of care. Some regulations and state practice acts require reevaluation at specific intervals. A reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services.
5. Reevaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline. A reevaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
Maintenance Program:
MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.
Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:
1. Establishment or design of maintenance programs
If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.
2. Delivery of maintenance programs
Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patient’s potential for improvement from the therapy.
3. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by non-skilled personnel or caregivers.
4. Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered occupational therapy services. Further, where the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered occupational therapy services.
5. Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered occupational therapy services. Further, where the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered occupational therapy services.
Audiological Treatment
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There is no provision in the law for Medicare to pay audiologists for therapeutic services. For example, vestibular treatment, auditory rehabilitation treatment, auditory processing treatment, and canalith repositioning, while they are generally within the scope of practice of audiologists, are not those hearing and balance assessment services that are defined as audiology services in 1861(ll)(3) of the Social Security Act and, therefore, shall not be billed by audiologists to Medicare. Services for the purpose of hearing aid evaluation and fitting are not covered regardless of how they are billed. Services identified as “always” therapy in Pub. 100-04, chapter 5, section 20 may not be billed by hospitals, physicians, NPPs, or audiologists when provided by audiologists.
Treatment related to hearing may be covered under the speech-language pathology benefit when the services are provided by speech-language pathologists. Treatment related to balance (e.g., services described by “always therapy” codes 97001-97004, 97110, 97112, 97116, and 97750) may be covered under the physical therapy or occupational therapy benefit when the services are provided by therapists or their assistants, where appropriate. Covered therapy services incident to a physician’s service must conform to policies in sections 60, 220, and 230 of this chapter. Audiological treatment provided under the benefits for physical therapy and speech-language pathology services may also be personally provided and billed by physicians and NPPs when the services are within their scope of practice and consistent with State and local laws.
For example, aural rehabilitation and signed communication training may be payable according to the benefit for speech-language pathology services or as speech-language pathology services incident to a physician’s or NPP’s service. Treatment for balance disorders may be payable according to the benefit for physical therapy services or as a physical therapy service incident to the services of a physician or NPP. See the policies in this chapter, sections 220 and 230, for details.
