Occupational therapy is covered to improve, sustain or restore functions, which have been lost or reduced as a result of injury, illness, cognitive impairment, psychosocial dysfunction, mental illness, or developmental, learning or physical disability. Occupational therapy is covered when rendered and billed by a licensed, registered occupational therapist or other authorized professional provider acting within the scope of his or her license. Professional services performed by a supervised licensed occupational therapy assistant (OTA) must be billed under the licensed occupational therapist’s National Provider Identification (NPI) number using the CO modifier. OTAs may not provide an initial examination, evaluation, assessment, or establish a diagnosis or plan of care.
All active duty service members (ADSMs), TRICARE Prime and TRICARE Prime Remote beneficiaries who have an assigned primary care manager (PCM) require an approval from Health Net Federal Services, LLC (HNFS) for occupational therapy services. TRICARE Prime Remote beneficiaries (excluding ADSMs) without an assigned PCM and TRICARE Select beneficiaries do not require an approval from HNFS prior to services being rendered; however, a physician’s order is required for claims processing.
Coverage is based on the beneficiary's medical needs. The number of visits authorized indicates the actual number of visits, not the individual units per CPT® code. The following baselines will be used as a guide for the number of visits and duration of approval:
- Acute injuries (for example, musculoskeletal conditions such as ankle sprain, shoulder sprain, low back pain or torn hamstring) = 12 visits with a duration of 120 days
- Post-operative care (for example, hip and knee replacement) = 24 visits with a duration of 150 days
- Long term conditions (for example, neurological conditions such as stroke, traumatic brain or spinal cord injury, pediatric neurodevelopmental conditions, swallow testing or feeding therapy) = 72 visits with a duration of 180 days
Individualized Education Program (IEP) requirements
Occupational therapy to treat a physical or occupational deficiency due to a cognitive or developmental disorder for beneficiaries ages three to 21 requires physician letter of attestation whenever there is evidence presented to TRICARE that there is an individualized education program in place for special education services. TRICARE may cover additional occupational therapy when a physician attests that the intensity and/or timeliness of any occupational therapy services offered by the educational agency does not meet the medical needs of the beneficiary.
The following occupational therapy services are not a covered benefit (this list is not all inclusive):
- diathermy, ultrasound and heat treatments for pulmonary conditions
- general exercise programs, even if recommended by a physician
- electrical nerve stimulation used in the treatment of upper motor neuron disorders such as multiple sclerosis
- repetitive exercise to improve gait, maintain strength and endurance, and assistive walking such as that provided in support of feeble or unstable patients
- range of motion and passive exercises, which are not related to restoration of a specific loss of function
- maintenance therapy that does not require a skilled level of assistance
- vocational assessment and training or assessments to determine status of disability
- services provided to address disorders or conditions resulting from occupational deficits
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