Although rehabilitative services are provided by occupational therapy (OT),
speech therapy and physical therapy (PT), this policy only addresses OT.  
  
OT is an integral component of rehabilitative services in the areas of
physical, cognitive and psychosocial impairment. OT is based on purposeful,
goal directed activity (occupation). The goal of OT is to prevent, improve or
restore physical and/or cognitive impairment following disease or injury.
Occupational therapists (OTs) utilize clinical history, observation,
interview, standardized testing and assessment of activities of daily living
skills (ADLs), work skills, and leisure skills to characterize individuals
with impairments, functional limitations and disabilities. The results of
these assessments are used to identify structural impairments and functional
limitations and to design an individualized plan of treatment to assist in
improving or restoring function. All OT services must be performed by or under
the supervision of a qualified OT.  
  
For the purposes of this Local Coverage Determination (LCD), the
descriptions/definitions of supervision are those given in 42 CFR
410.32(b)(3).  
  
Qualified OT: An individual who is licensed as an OT and meets the practice
requirements in the state where they are practicing.  
  
For outpatient settings, references to "physicians" throughout this policy
include nonphysician practitioners (NPPs), such as nurse practitioners,
clinical nurse specialists and physician assistants. Such NPPs may certify,
order and establish the plan of care (POC) for services by OTs as authorized
by state law.  
  
A qualified OT, for program coverage purposes, is defined as an individual who
is licensed as an OT and meets the practice requirements in the state where
they are practicing. Physiatrists, physicians or NPPs, and qualified OTs have
the knowledge, training, and experience required to evaluate and, as
necessary, re-evaluate a patient's level of function, and determine whether an
OT program could reasonably be expected to improve, restore or compensate for
lost function. Where appropriate, the OT can recommend to the physician or NPP
a POC. While the skills of a qualified OT are required to evaluate the
patient's level of function and develop a POC, implementation of the plan may
also be carried out by a qualified occupational therapy assistant (OTA)
functioning under the general supervision of the qualified OT.

**NOTE:** Some services must be provided by a licensed therapist and may not
be performed by an OTA. Such services include:

  * Making clinical judgements or decisions
  * Developing, managing or furnishing skilled maintenance programs
  * Supervising other clinicians or taking responsibility for the service rendered
  * Acting outside of the direction and supervision of a treating OT in accordance with state laws

**Restorative/Rehabilitative therapy:**  
  
In evaluating a claim for skilled therapy that is restorative/rehabilitative
(i.e., whose goal and/or purpose is to reverse, in whole or in part, a
previous loss of function), it would be entirely appropriate to consider the
beneficiary's potential for improvement from the services. The Centers for
Medicare & Medicaid Services (CMS) notes that such a consideration must always
be made in the inpatient rehabilitation facility (IRF) setting where skilled
therapy must be reasonably expected to improve the patient's functional
capacity or adaptation to impairments in order to be covered.  
  
 **Maintenance therapy:**

A maintenance program is a program designed to maintain or to slow
deterioration as described in the CMS Internet-Only Manual, Pub. 100-02,
Medicare Benefit Policy Manual, Chapter 15, 220 and 220.2 and must meet
these criteria to be considered reasonable and necessary.

The treatment approach includes:

a) evaluation  
  
b) basic activities of daily living (BADLs) training  
  
c) instrumental activities of daily living (IADLs) training  
  
d) muscle reeducation/strengthening/coordination  
  
e) cognitive training  
  
f) perceptual motor training  
  
g) orthotics (splinting)  
  
h) adaptive equipment fabrication and training  
  
i) environment modification recommendations/training  
  
j) patient/caregiver education/training  
  
k) transfer training  
  
l) functional modality training  
  
m) manual therapy  
  
n) physical agent modality

**GENERAL OT GUIDELINES**  
  
1\. OT services are covered services provided the services are of a level of
complexity and sophistication, or the patient's condition is such that the
services can be safely and effectively performed only by a licensed OT or
under his/her supervision. Services normally considered a routine part of
nursing care are not covered as OT (i.e., provide ADLs for patient with no
rehabilitation potential).  
  
2\. In order for the plan of treatment to be covered, it must address a
condition for which OT is an accepted method of treatment as defined by
standards of medical practice. Also, the plan of treatment must be for a
condition that is expected to improve significantly within a reasonable and
generally predictable period of time or establishes a safe and effective
maintenance program. If at any point in the treatment of an illness or injury
it is determined that the treatment is not rehabilitative or does not
legitimately require the services of a qualified professional for management
of a maintenance program, the services will no longer be considered reasonable
and necessary and are excluded from coverage.  
  
3\. Covered OT services must be furnished while the individual is or was under
the care of a physician. Services must relate directly and specifically to a
written plan of treatment. The plan of treatment should address specific
therapeutic goals, for which modalities and procedures are planned out
specifically in terms of type, frequency and duration. The physician or NPP
should periodically review the plan of treatment.  
  
4\. The physician, NPP and/or therapist must document the patient's functional
limitations in terms that are objective and measurable.  
  
 **SPECIFIC PROCEDURE AND MODALITY GUIDELINES**  
  
 **Computerized Dynamic Posturography**  
  
Computerized dynamic posturography is a "quantitative method for assessing
balance functioning under various simulated tasks. Protocols are designed to
test the sensory, motor and biomechanical components of balance individually
and in concert." Computerized dynamic posturography "may assist with lesion
localization, identifying adaptive strategies and functional capabilities."  
  
 ***Note:** Results of computerized dynamic posturography must be used in
determining the patient centered POC.  
  
**Fabrication/Application of Casts, Splints and Strapping**  
  
Fabrication and application of casts, splints, and strapping will be
considered reasonable and necessary if used to support weak, post-surgical or
ineffective joints/muscles, for facilitating increased motor response, to
assist in compensation in a permanent loss of motor function, reduce/correct
joint limitations/deformities and/or protect body parts from injury, thus
enhancing the performance of tasks or movements. The casts, splints and
strapping are often used in conjunction with therapeutic exercise, functional
training, other interventions, and should be selected in the context of
patient's needs, social/culture environments, BADLs and IADLs.  
 **  _ _**  
 **BODY AND UPPER EXTREMITY CASTS**  
  
 **Application of long arm cast  **  
  
May be indicated for the shoulder and/or elbow in the treatment of fractures,
dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment
of spasticity, contractures and/or other deformities involving soft tissue.  
  
 **Application of short arm  cast **  
  
May be indicated for the forearm, wrist, and/or elbow in the treatment of
fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
treatment of spasticity, contractures and/or other deformities involving soft
tissue.  
  
 **Application of hand and lower forearm cast  **  
  
May be indicated for the forearm, wrist, and/or hand in the treatment of
fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
treatment of spasticity, contractures and/or other deformities involving soft
tissue.  
  
 **Application of finger cast (e.g., contracture)**  
  
May be indicated for the finger in the treatment of fractures, dislocations,
sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity,
contractures and/or other deformities involving soft tissue.  
  
 **SPLINTS**  
  
 **Application of long arm splint**  
  
May be indicated for the shoulder and/or elbow in the treatment of fractures,
dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment
of spasticity, contractures or other deformities involving soft tissue.  
  
**Application of short arm splint**  
  
May be indicated for the forearm, wrist and/or hand in the treatment of
fractures, dislocations, sprain/strains, tendonitis, post-op reconstruction,
treatment of spasticity, contractures or other deformities involving soft
tissue.  
  
**Application of finger splint**  
  
May be indicated for the finger in the treatment of fractures, dislocations,
sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity,
contractures or other deformities involving soft tissue.  
  
 **STRAPPING-ANY AGE**  
  
 **Strapping of thorax**  
  
May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal
musculature in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, neuromuscular conditions, contractures,
or other deformities involving soft tissue.  
  
**Strapping of low back**  
  
May be indicated for the lumbar spine, rib cage or abdominal musculature in
the treatment of contusions, dislocations, fractures, sprain/strains, post-op
conditions, neuromuscular conditions, contractures or other deformities
involving soft tissue.  
  
 **Strapping of shoulder (e.g., Velpeau)**  
  
May be indicated for any portion of the shoulder girdle complex, or rib cage
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
 **Strapping of elbow or wrist**  
  
May be indicated for the elbow or wrist when there is involvement of the
humerus, forearm, wrist, or hand in the treatment of contusions, dislocations,
fractures, sprains/strains, post-op conditions, neuromuscular conditions,
edema, scar management, contractures or other deformities involving soft
tissue.  
  
 **Strapping of hand or finger**  
  
May be indicated where there is involvement of the hand or finger(s) in the
treatment of contusions, dislocations, fractures, sprains/strains, post-op
conditions, neuromuscular conditions, edema, scar management, contractures or
other deformities involving soft tissue.  
  
**LOWER EXTREMITY CASTS**  
  
 **Application of long leg cast**  
  
May be indicated when there is involvement of the femur, patella, tibia,
fibula, ankle or foot in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, contractures or other deformities
involving soft tissue.  
  
 **Application of short leg cast**  
  
May be indicated when there is involvement of the tibia, fibula, ankle or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, contractures or other deformities involving soft tissue.  
  
 **SPLINTS**  
  
 **Application of long leg splint**  
  
May be indicated when there is involvement of the femur, patella, tibia,
fibula, ankle or foot in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, contractures or other deformities
involving soft tissue.  
  
 **Application of short leg splint**  
  
May be indicated when there is involvement of the tibia, fibula, ankle or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, contractures or other deformities involving soft tissue.  
  
**STRAPPING ANY AGE**  
  
 **Strapping of hip**  
  
May be indicated when there is involvement of the lower back, abdomen or hip
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
 **Strapping of knee**  
  
May be indicated when there is involvement of the thigh, knee or lower leg in
the treatment of contusions, dislocations, fractures, sprains/strains, post-op
conditions, neuromuscular conditions, contractures or other deformities
involving soft tissue.  
  
**Strapping of ankle and/or foot**  
  
May be indicated when there is involvement of the lower leg, ankle and/or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
**Strapping of toes**  
  
May be indicated when there is involvement of any of the toes in the treatment
of contusions, dislocations, fractures, sprains/strains, post-op conditions,
neuromuscular conditions, contractures or other deformities involving soft
tissue.  
  
 **Biofeedback Training by any method and biofeedback training perineal
muscles, anorectal or urethral sphincter including EMG and/or manometry**  
  
The coverage criteria and definition of biofeedback therapy are found in the
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 1, 30.1 and 30.1.1.  
  
"Biofeedback is a tool utilized by OTs to assist with muscle training. This
includes facilitation of muscles that are demonstrating suboptimal performance
as well as relaxation of muscles that may be inhibiting coordinated movement.
Biofeedback can be visual or auditory."  
  
 **Evaluation of oral and pharyngeal swallowing function**  
  
The evaluation of oropharyngeal swallowing dysfunction includes the phases of
oral preparatory, oral/voluntary and pharyngeal in reference to oral and
motility problems in the oral cavity and pharynx.  
  
The clinical examination may include:

a)  A history of the patient's disorder and awareness of the swallowing
disorder, and indications of the localization and nature of the disorder  
  
b) Medical status including nutritional and respiratory status  
  
c) Oral anatomy/physiology (labial control, lingual control, palatal function)  
  
d) Pharyngeal function  
  
e) Laryngeal function  
  
f) Ability to follow directions; alertness  
  
g) Efforts and interventions used to facilitate normal swallow (compensatory
strategies such as chin tuck, dietary changes, etc.)  
  
h) Identifying symptoms during attempts to swallow

The clinical examination can be divided into 2 phases:  
  
1\. The preparatory examination with no swallow, and  
2\. The initial swallow examination with actual swallow while physiology is
observed  
  
 **__ Note:** Based on the findings, an instrumental exam may be recommended.  
  
 **Treatment of swallowing dysfunction and/or oral function for feeding**  
  
This involves the treatment for the impairments/functional limitations of
mastication, the preparatory phase, oral phase, pharyngeal phase, and
esophageal phase of swallowing. Appropriate recommendations will be made
regarding diet and compensatory techniques and instruction given in
direct/indirect therapies to facilitate oral motor control for feeding.  
  
 **Muscle testing, manual**

Manual testing "are intended to report manual test of muscles or muscle groups
for strength based on grading scales."  
  
 **Muscle testing, manual (separate procedure); extremity (excluding hand) or
trunk, with report  **  
  
Every muscle of at least 1 extremity would need to be tested, with
documentation of why such a thorough assessment was warranted.  
  
 **Muscle testing, manual (separate procedure) with report; hand, with or
without comparison with normal side  **  
  
 **Muscle testing, manual (separate procedure) with report; total evaluation
of body, excluding hands or including hands  **  
  
The measurement of muscle performance using manual muscle testing only.  
  
 **Range of Motion (ROM) Measurements  **  
  
This is the determination of ROM using a tape measure, flexible ruler,
electronic device or goniometer.

Every joint of an extremity would need to be tested, with documentation of why
such a thorough assessment was warranted for extremity ROM testing.

**Developmental Testing; with interpretation and report**  
  
Developmental testing are services provided during testing of the cognitive
function of the central nervous system.  
  
 **Standardized Cognitive Performance Testing  **  
  
Neuropsychological testing (e.g., Ross Information Processing Assessment,
LOTCA- Loewenstein OT Cognitive Assessment, MVPT - Motor-Free Visual
Perception Test, ACL - Allen Cognitive Test), __ per hour of the OT's time,
both face-to-face time administering tests to the patient and time
interpreting these test results and preparing the report. This is usually done
outside the OTs initial evaluation/re-evaluation.  
  
**OT Evaluation  and OT Re-evaluation **  
  
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 POC, 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  
  
   b. Relevant systems review  
  
   c. Tests and measures  
  
   d. Current functional status (abilities and deficits)  
  
   e. Evaluation of patient's, physician's, NPP'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, and the patient's overall physical and cognitive health
status. 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. OTs also consider the level of the current impairments and
the probability of prolonged impairment, functional limitation, disability,
the living environment, prior level of function, the social/cultural supports,
psychosocial factors, and use of adaptive equipment.  
  
3\. Initial evaluations or re-evaluations 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\. Re-evaluation 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 POC.
Some regulations and state practice acts require re-evaluation at specific
intervals. A re-evaluation 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. OTAs may assist the OT in a
re-evaluation within their scope of practice by gathering objective data,
tests, measurements, etc.; however, the OT must actively and personally
participate in the re-evaluation and is responsible for the assessment and the
POC.  
  
5\. A re-evaluation 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 PROGRAMS** _  
_

A maintenance program is a program intended to maintain function or slow the
decline in function. Coverage of skilled rehabilitation services is contingent
upon a beneficiary's need for skilled care. When a program to maintain or
reduce decline in functional status requires the skills of a licensed
therapist to be performed safely and effectively, provision of skilled
services for the execution of that therapy program is covered. The skilled
need must come from the nature of the service being rendered and the patient's
unique circumstance. The provision of therapy services by skilled therapy
personnel does not itself make the service one that requires skilled care.

**Hot or Cold Packs Therapy  **  
  
Hot or cold packs are used primarily in conjunction with therapeutic
procedures to provide analgesia, relieve muscle spasm and reduce inflammation
and edema. Typically, cold packs are used for acute, painful conditions, and
hot packs are used for subacute or chronic painful conditions.  
  
 **Mechanical Traction Therapy**  
  
1\. Traction is generally limited to the cervical or lumbar spine with the
hope of relieving pain in or originating from those areas.  
  
2\. Specific indications for the use of mechanical traction include:

a. Cervical and/or lumbar radiculopathy  
b. Back disorders such as disc herniation, lumbago, and sciatica

**Vasopneumatic Device Therapy**  
  
1\. The use of vasopneumatic devices may be considered reasonable and
necessary for the application of pressure to an extremity for the purpose of
reducing edema.  
  
2\. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury  
b. Lymphedema of an extremity  
c. Education and training on the use of vasopneumatic devices for home use

**Note:** Further treatment on the use of vasopneumatic devices by OTs, after
the education and training visits, is usually not reasonable and necessary.
Generally, education and training can be completed in 3 visits.  
  
 **Paraffin Bath**  
  
Paraffin bath, also known as hot wax treatment, is primarily used for pain
relief in chronic joint problems or the wrist, hands, and feet.  
  
Heat treatments of this type do not ordinarily require the skills of a
qualified OT. However, in a particular case, the skills, knowledge and
judgment of a qualified OT might be required in such treatments or baths,
e.g., where the patient's condition is complicated by circulatory deficiency,
areas of desensitization, open wounds, fractures, or other complications.
Also, if such treatments are given prior to but as an integral part of a
skilled OT procedure, the treatments would be considered part of the OT
service.  
  
**Whirlpool/Hubbard Tank**  
  
1\. Heat treatments of this type and whirlpool baths do not ordinarily require
the skills of a qualified OT. However, in a particular case, the skills,
knowledge and judgment of a qualified OT might be required in such treatments
or baths, e.g., where the patient's condition is complicated by circulatory
deficiency, areas of desensitization, open wounds, fractures, or other
complications. Also, if such treatments are given prior to but as an integral
part of a skilled OT procedure, the treatment would be considered part of the
skilled OT service.  
  
2\. Whirlpool bath and Hubbard Tanks are the most common forms of
hydrotherapy. The use of whirlpool is considered reasonable and necessary when
used as part of a plan directed at facilitating the healing of an open wound
(e.g., burns).  
  
3\. Specific indications for the use of whirlpools include the following:

a. The patient having a documented open wound which is draining, has a foul
odor, or evidence of necrotic tissue  
  
b. The patient having a documented need for wound debridement/bandage removal  
  
c. Exfoliative skin impairments

**Fluidized Therapy Dry Heat For Certain Musculoskeletal Disorders (Dry
Whirlpool)**  
  
The coverage criteria and definition of fluidized therapy dry heat (dry
whirlpool) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare
National Coverage Determinations Manual, Chapter 1, Part 2, 150.8.  
  
**Diathermy Treatment**  
  
Diathermy coverage criteria and definition are found in the CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter
1, Part 2, 150.5 and Part 4, 240.3.  
  
 **Infrared Therapy Devices**  
  
Noncoverage of Infrared Therapy Devices is described in the CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter
1, Part 4, 270.6.  
  
**Electrical Stimulation  **  
  
Electrical stimulation requires "visual, verbal and/or manual contact" (i.e.,
constant attendance). This requires 1-on-1 instruction for subsequent home use
of Transcutaneous Electrical Nerve Stimulation (TENS) unit.  
  
TENS is not reasonable and necessary for the treatment of Chronic Low Back
Pain (CLBP) under 1862(a)(1)(A) of the Social Security Act.

**Electrical Stimulation Therapy-Unattended**  
  
Electrical stimulation therapy and definition are found in the CMS Internet-
Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Part 4, 270.1.  
  
 **Electromagnetic Therapy**  
  
Electromagnetic therapy criteria and definition are found in the CMS Internet-
Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Part 4, 270.1.  
  
 **Iontophoresis Application**  
  
1\. Iontophoresis is a process in which electrically charged molecules or
atoms (i.e., ions) are driven into tissue with an electrical field. Voltage
provides the driving force. Parameters, such as drug polarity and
electrophoretic mobility must be known in order to be able to assess whether
iontophoresis can deliver therapeutic concentrations of a medication at sites
below the skin.  
  
2\. The application of iontophoresis is considered reasonable and necessary
for the topical delivery of medications into a specific area of the body.  
  
3\. Specific indications for the use of iontophoresis application may include
but are not limited to patients having:

a. Tendonitis or calcific tendonitis  
  
b. Bursitis  
  
c. Adhesive capsulitis  
  
d. Hyperhidrosis  
  
e. Thick adhesive scar(s)

**Contrast Baths**  
  
1\. Contrast baths are a special form of therapeutic heat and cold that can be
applied to distal extremities. The effectiveness of contrast baths is thought
to be due to reflex hyperemia produced by the alternating exposure to heat and
cold. Although a variety of applications are possible, contrast baths often
are used in treatment to decrease edema and inflammation.  
  
2\. The use of contrast baths is considered reasonable and necessary to
desensitize patients to pain by reflex hyperemia produced by the alternating
exposure to heat and cold.  
  
3\. Specific indications for the use of contrast baths include:

a. The patient having rheumatoid arthritis or other inflammatory arthritis  
  
b. The patient having reflex sympathetic dystrophy  
  
c. The patient having a sprain or strain resulting from an acute injury

4\. Heat treatments of this type and contrast baths do not ordinarily require
the skills of a qualified OT. However, in a particular case, the skills,
knowledge and judgment of a qualified OT might be required in such treatments
or baths, e.g., where the patient's condition is complicated by circulatory
deficiency, areas of desensitization, open wounds, fractures, or other
complications. If such treatments were given prior to but as an integral part
of a skilled OT procedure, the treatment would be considered part of the
skilled OT service.  
  
**Ultrasound (US)**  
  
1\. Therapeutic US is a deep heating modality that produces a sound wave of
0.8 to 3.0 MHz. In the human body, US has several pronounced effects on
biologic tissues. It is attenuated by certain tissues and reflected by bone.
Thus, tissues lying immediately next to bone can receive an even greater
dosage of US, as much as 30% more. Because of the increased extensibility US
produces in tissues of high collagen content, combined with the close
proximity of joint capsules, tendons, and ligaments to cortical bone where
they receive a more intense irradiation, it is an ideal modality for
increasing mobility in those tissues with restricted ROM.  
  
2\. The application of US is considered reasonable and necessary for patients
requiring deep heat to a specific area for reduction of pain, spasm, and joint
stiffness, and the increase of muscle, tendon and ligament flexibility.  
  
3\. Specific indications for the use of US application include:

a. The patient having tightened structures limiting joint motion that require
an increase in extensibility  
  
b. The patient having symptomatic soft tissue calcification  
  
c. The patient having neuromas

**Note:** US is **not** considered to be reasonable and necessary for the
treatment of asthma, bronchitis or any other pulmonary condition.  
  
 **GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES:**  
  
1\. Therapeutic procedures are procedures that attempt to reduce impairments
and improve function through the application of clinical skills and/or
services.  
  
2\. Use of these procedures requires that these services be rendered under the
supervision of an OT.  
  
3\. Therapeutic exercises and neuromuscular reeducation are examples of
therapeutic interventions. The expected goals documented in the written plan
of treatment, effected by the use of each of these procedures, will help
define whether these procedures are reasonable and necessary. Therefore, since
any 1 or a combination of more than 1 of these procedures may be used in a
written plan of treatment, documentation must support the use of each
procedure as it relates to a specific therapeutic goal.  
  
4\. Services provided concurrently by an OT, PT and speech therapist may be
covered, if separate and distinct goals are documented in the written plan of
treatment.  
  
5\. Require (1-on-1) direct patient contact, unless otherwise stated.  
  
 **Therapeutic Exercise**  
  
1\. Therapeutic exercise is performed with a patient either actively, active-
assisted, or passively participating (e.g., isokinetic exercise, stretching,
strengthening and gross and fine motor movement).  
  
2\. Therapeutic exercise may address impairments of exercise tolerance due to
cardiopulmonary impairments. Therapeutic exercise with an individualized
physical conditioning and exercise program using proper breathing techniques
can be considered for a patient with activity limitations secondary to
cardiopulmonary impairments.  
  
3\. Therapeutic exercise is considered reasonable and necessary if at least 1
of the following conditions is present and documented:

a. The patient having weakness, contracture, stiffness secondary to spasm,
spasticity, decreased joint ROM, functional mobility deficits, balance and/or
coordination deficits, abnormal posture, muscle imbalance

b. The patient needing to improve mobility, flexibility, strengthening,
coordination, control of extremities, dexterity, ROM, or endurance as part of
ADL training, or reeducation

4\. Documentation for therapeutic exercise typically includes objective loss
of joint motion, strength, and /or mobility (e.g., degrees of motion, strength
grades, levels of assistance).  
  
 **Neuromuscular Reeducation**  
  
1\. This therapeutic procedure is provided to improve balance, coordination,
kinesthetic sense, posture, motor planning, body awareness, and proprioception
(e.g., proprioceptive neuromuscular facilitation, Feldenkrais, Bobath).  
  
2\. Neuromuscular reeducation may be considered reasonable and necessary for
impairments, which affect the body's neuromuscular system (e.g., poor static
or dynamic sitting/standing balance, loss of gross and fine motor
coordination, desensitization, proprioception, hypo/hypersensitivity,
hypo/hypertonicity, and neglect).  
  
**Aquatic Therapy with Therapeutic Exercises**  
  
"Aquatic therapy describes therapeutic exercises performed in a water-based
environment. The properties and temperature of the water facilitate movement,
particularly for muscles that are compromised due to injury, surgery, or
disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint
arthroplasty)." It is important for the OT to document the need for exercises
performed in a water-environment vs. land-based exercise. There should be a
plan for transitioning from water-based exercises to land-based exercises.  
  
1\. This procedure uses the therapeutic properties of water (e.g., buoyancy,
resistance). The procedure may be reasonable and necessary for a loss or
restriction of joint motion, strength, or mobility (e.g., degrees or motion,
strength grades, levels of assistance).  
  
2\. Aquatic therapy with therapeutic exercise may be considered reasonable and
necessary in the treatment of the following conditions:

a. The patient having pain, joint stiffness or muscle spasms resulting from
rheumatoid arthritis  
  
b. The patient having had a cast removed or recent surgery and requiring
mobilization of limbs  
  
c. The patient having paraparesis or hemiparesis  
  
d. The patient having a recent amputation  
  
e. The patient recovery from a paralytic condition  
  
f. The patient requiring limb mobilization after a head trauma  
  
g. The patient having the inability to tolerate exercise for rehabilitation
under gravity-based weight bearing  
  
h. The patient having fibromyalgia

**Massage Therapy**  
  
1\. Massage is the application of systemic manipulation to the soft tissues of
the body for therapeutic purposes. Although various assistive devices and
electrical equipment are available for the purpose of delivering massage, use
of the hands is considered the most effective method of application, because
palpation can be used as an assessment, as well as a treatment tool.  
  
2\. Massage therapy, including effleurage, petrissage, and/or tapotement
(stroking, compression, percussion) may be considered reasonable and necessary
if at least 1 of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired
circulation  
  
b. The patient having sensitivity of tissues to pressure  
  
c. The patient having tight muscles resulting in shortening and/or spasticity
of affective muscles  
  
d. The patient having abnormal adherence of tissue to surrounding tissue  
  
e. The patient requiring relaxation in preparation for neuromuscular
reeducation or therapeutic exercise  
  
f. The patient having contractures and decreased ROM

**Manual Therapy Techniques  **  
  
 **1\. Joint Mobilization (Peripheral or Spinal)**  
  
This procedure may be considered reasonable and necessary if restricted joint
motion is present and documented. It may be reasonable and necessary as an
adjunct to therapeutic exercises when loss of articular motion and flexibility
impedes the therapeutic procedure.  
  
 **2\. Soft Tissue Mobilization**  
  
This procedure involves the application of skilled manual therapy techniques
(active or passive) to soft tissues in order to effect changes in the soft
tissues, articular structures, neural or vascular systems. Examples are
facilitation of fluid exchange, restoration of movement in acutely edematous
muscles, or stretching of shortened muscular or connective tissue.  
  
Myofascial release/soft tissue mobilization can be considered reasonable and
necessary if at least 1 of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity,
neck or trunk  
  
b. Treatment being a necessary adjunct to other OT interventions

**3\. Manipulation**  
  
This procedure may be considered reasonable and necessary for treatment of
painful spasm, the loss of articular motion, or restricted motion of soft
tissues or joints. It may also be used as an adjunct to other therapeutic
procedures.  
  
 **4\. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy**  
  
The goal of this type of therapy is to reduce lymphedema by routing the fluid
to functional pathways, preventing backflow as the new routes become
established, and to use the most appropriate methods to maintain the reduction
after therapy is complete. This therapy involves intensive treatment to reduce
the size by a combination of manual decongestive therapy and serial
compression bandaging, followed by an exercise program.

a. It is expected that during these sessions, education is being provided to
the patient and/or caregiver on the correct application of the compression
bandage  
  
b. It is also expected that after the completion of the therapy, the patient
and/or caregiver can perform these activities without supervision

**Group Therapeutic Procedure(s)**  
  
A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapist receiving active therapy but not 1-on-1
treatment, and  
  
b. The patients may be performing the same exercise or a different exercise,
but the OT is instructing all the patients in the group.

**Note:** Regardless of the procedure or modality being performed, if the
patient is not receiving direct 1-on-1 contact but is being supervised by the
therapist it is considered the group therapy.  
  
 **Orthotics Training  **  
  
1\. This procedure may be considered reasonable and necessary, if there is an
indication for education for the application of orthotics, and the functional
use of the orthotic is present and documented.  
  
2\. Generally, orthotic training can be completed in 3 visits; however, for
modification of the orthotic due to healing of tissues, change in edema, or
impairment in skin integrity, additional visits may be required.  
  
3\. The medical record should document the distinct treatments rendered when
orthotic training for an upper and/or lower extremity is done.  
  
4\. The patient is capable of being trained to use the particular device
prescribed in an appropriate manner. In some cases, the patient may not be
able to perform this function, but a responsible individual can be trained to
apply the device.  
  
 **Prosthetic Training  **  
  
1\. This procedure and training may be considered reasonable and necessary, if
there is an indication for education in the application of the prosthesis, and
the functional use of the prosthesis is present and documented.  
  
2\. The medical record should document the distinct goals and service rendered
when prosthetic training for an upper and/or lower extremity is done.  
  
3\. Periodic revisits beyond the third month would require documentation to
support medical necessity.  
  
 **Orthotic/Prosthetic Checkout**  
  
1\. These assessments are reasonable and necessary when there is a
modification or reissue of a recently issued device or a reassessment of a
newly issued device.  
  
2\. These assessments may be reasonable and necessary when patients experience
a loss of function directly related to the device (e.g., pain, skin breakdown,
and falls).  
  
3\. These assessments may be reasonable and necessary for determining "the
patient's response to wearing the device, determining whether the patient is
donning/doffing the device correctly, determining the patient's need for
padding, under wrap, or socks and determining the patient's tolerance to any
dynamic forces being applied."  
  
**Therapeutic Activities**  
  
1\. Therapeutic activities are considered reasonable and necessary for
patients needing a broad range of rehabilitative techniques. Activities can be
for a specific body part or could involve the entire body. This procedure
involves the use of functional activities to improve performance in a
progressive manner. The activities are usually directed at a loss or
impairment of mobility, strength, balance, coordination or cognition. They
require the skills of an OT and are designed to address a specific functional
need of the patient. These dynamic activities must be part of an active
written plan of treatment and be directed at a specific outcome.  
  
2\. In order for therapeutic activities to be covered, the following
requirements must be met:

a. The patient having a condition for which therapeutic activities can
reasonably be expected to restore or improve functioning  
  
b. The patient's condition being such that he/she is unable to perform
therapeutic activities except under the supervision of an OT  
  
c. There being a clear correlation between the type of exercise performed and
the patient's underlying medical condition for which the therapeutic
activities were prescribed

**Cognitive Skills Development**  
  
1\. This procedure is reasonable and necessary for patients who have a disease
or injury in which impairment of cognitive functioning is documented. Impaired
functions may include, but are not limited to:

 ability to follow simple commands  
 ability to focus on a task  
 improve problem solving skills  
 improve memory  
 ability to follow numerous steps in a process  
 ability to complete a logical sequence task  
 ability to organize parts of concepts or thoughts into a whole

2\. This procedure is reasonable and necessary only when it requires the
skills of an OT and is designed to address specific needs of the patient and
is part of the written POC.  
  
3\. Treatment techniques utilized include, but are not limited to: recall of
information, tabletop graded activities focusing on attentional skills (e.g.,
cancellation tasks, mazes), graded processes in steps which the patient must
follow to complete the task, and computer programs that focus on the above.  
  
4\. Development of cognitive skills must be reasonable and necessary to
restore and improve functioning of the patient. Documentation must relate the
training to expected functional goals that are attainable by the patient.  
  
5\. Services provided concurrently by physicians, NPPs, OTs and speech
therapists may be covered, if separate and distinct goals are documented in
the written plan of treatment.  
  
 **Sensory Integrative Techniques**  
  
The use of sensory integrative techniques is considered reasonable and
necessary when patients must develop adaptive skills for sensory processing.
When there has been a disruption of the auditory, vestibular, proprioceptive,
tactile and/or visual system, interventions are required to assist the patient
in remaining functional in their environment. The loss of sensory systems
often compromises the safety of the patient; therefore, therapy should provide
adaptations that allow the patient to interact with their environment to
promote well-being.  
  
**Self-Care/Home Management Training**  
  
The coverage criteria of self-care/home management training is found in the
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 3, 170.1.  
  
"Self-care/home management training describes a group of interventions that
focuses on ADL skills and compensatory activities needed to achieve
independence or adapt to an evolving deterioration in health and function.
These include activities such as dressing, bathing, food preparation, and
cooking. The patient/client may require adaptive equipment and/or assistive
technology in the home environment. This includes training the patient/client
and/or caregiver in the use of the equipment."  
  
 **Community/Work Reintegration Training**  
  
Services that are related **solely** to specific employment opportunities,
work skills, or work settings are not reasonable and necessary for the
diagnosis and treatment of an illness or injury and are excluded from coverage
by 1862(a)(1)(A) of the Social Security Act.  
  
Services that are covered include complex IADLs a person must do to maintain
independence in the community. These tasks involve interaction with the
physical and social environment. Examples of these activities may include
telephone skills, written communication, handling mail, use of money,
shopping, emergency procedure use/skills and use of assistive technology
device/adaptive equipment. This service is only covered when the skilled
intervention of OT is required to achieve established goals.  
  
**Work Hardening/Conditioning**  
  
"Work hardening and work conditioning are different interventions. Work
hardening is an interdisciplinary program that is focused on tasks required
for a specific job and uses real or simulated work activities to restore
physical, behavioral, and vocational functions. Work hardening addresses
productivity, safety, physical tolerances, and worker behavior. In contrast,
work conditioning describes a work-related, intensive treatment program
designed to restore strength, flexibility, and function so that the
patient/client can return to work." These interventions are not covered.  
  
 **Wheelchair Management Training  **  
  
Wheelchair management "includes assessing if the patient/client needs a
wheelchair, determining what kind of wheelchair is appropriate, including its
size and components, measuring the patient/client to ensure proper fit, and
fitting the patient/client into the chair once it is received. It also
includes time associated with training the patient/client and/or caregiver in
transfers in and out of the chair as well as propulsion on all surfaces. It is
important for the therapist to provide instructions for safety so as not to
risk skin breakdown or a fall."  
  
1\. This service trains the patient in functional activities that promote
optimal safety, mobility and transfers. Patients who use wheelchairs for
mobility may occasionally need skilled input on positioning to avoid pressure
points, contractures, and other medical complications.  
  
2\. This procedure is reasonable and necessary only when it requires the
skills of an OT and is designed to address specific needs of the patient and
must be part of an active written plan of treatment directed at a specific
goal.  
  
3\. The patient and/or caregiver must have the capacity to learn from
instructions.  
  
4\. Typically, 3 to 4 sessions should be sufficient to teach the patient
and/or caregiver these skills.  
  
5\. For wheelchair propulsion training, documentation should relate the
training to expected functional goals that are attainable by the patient.  
  
 **Wound Care Selective Debridement  **  
  
 **a) Debridement**  
  
Debridement is indicated whenever necrotic tissue is present on a documented
open wound. Debridement may also be indicated in cases of abnormal wound
repair. Debridement techniques usually progress from non-selective to
selective but can be combined. Debridement will not be considered a reasonable
and necessary procedure for a wound that is clean and free of necrotic tissue.  
  
**b) Conservative Sharp Debridement**  
  
Conservative sharp debridement is a minor procedure that requires no
anesthesia and is performed on an outpatient basis. Scalpel, scissors, forceps
and high-pressure waterjet may be used and only clearly identified devitalized
tissue is removed. Generally, there is no bleeding associated with this
procedure.  
  
 **Wound(s) Care Non-Selective Debridement and Negative Pressure Wound Therapy
**  
  
 **a) Enzymatic Debridement**  
  
Debridement with topical enzymes is used when necrotic substances to be
removed from a wound are protein, fibrin and collagen. The manufacturer's
product insert contains indications, contraindications, precautions, dosage,
and administration. It would be the clinician's responsibility to comply with
the product insert/guidelines.  
  
 **b) Autolytic Debridement**  
  
This type of debridement is indicated where manageable amounts of necrotic
tissue are present, and there is no infection. Autolytic debridement occurs
when the enzymes that are naturally found in wound fluids are sequestered
under synthetic dressings. Autolytic debridement is contraindicated for wounds
that contain infection.  
  
 **c) Mechanical Debridement**  
  
Wet-to-moist dressings may be used with wounds that have a high percentage of
necrotic tissue. Wet-to-moist dressings should be used cautiously as
maceration of surrounding tissue may hinder healing.  
  
Hydrotherapy and wound irrigation are also forms of mechanical debridement
used to remove necrotic tissue. They also should be used cautiously, as
maceration of surrounding tissue may hinder healing.  
  
 **d) Negative Pressure Wound Therapy**  
  
Negative Pressure Wound Therapy is a non-invasive treatment, by which
controlled localized negative pressure is delivered to a wide variety of
acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should
be used cautiously as maceration of surrounding tissue may hinder healing.  
  
 **Physical Performance Test or Measurement**  
  
This testing may be reasonable and necessary for patients with neurological or
musculoskeletal conditions, when such tests are needed to formulate or
evaluate a specific written plan of treatment, or to determine a patient's
functional capacity.  
  
 **Assistive Technology Assessment**  
  
This assessment requires professional skill to gather data by observation and
patient inquiry and may include limited objective testing and measurement to
make clinical judgments regarding the patient's condition(s). Assessment
determines, e.g., changes in the patient's status since the last visit and
whether the planned procedure or service should be modified. Based on these
assessment data, the professional may make judgment about progress toward
goals and/or determine that a more complete evaluation or re-evaluation is
indicated.