Page 220 - Medicare Benefit Policy Manual

The cost of supplies (e.g., looms, ceramic tiles, or leather) used in furnishing covered
therapy care is included in the payment for the HCPCS codes billed by the occupational
therapist and are, therefore, not separately billable. Separate coverage and billing
provisions apply to items that meet the definition of brace in §130 of this manual.

Services provided by aides, even if under the supervision of a therapist, are not therapy
services in the outpatient setting and are not covered by Medicare. Although an aide may
help the therapist by providing unskilled services, those services that are unskilled are not
covered by Medicare and shall be denied as not reasonable and necessary if they are
billed as therapy services.

D. Application of Medicare Guidelines to Occupational Therapy Services

Occupational therapy may be required for a patient with a specific diagnosed psychiatric
illness. If such services are required, they are covered assuming the coverage criteria are
met. However, where an individual’s motivational needs are not related to a specific
diagnosed psychiatric illness, the meeting of such needs does not usually require an
individualized therapeutic program. Such needs can be met through general activity
programs or the efforts of other professional personnel involved in the care of the patient.
Patient motivation is an appropriate and inherent function of all health disciplines, which
is interwoven with other functions performed by such personnel for the patient.
Accordingly, since the special skills of an occupational therapist are not required, an
occupational therapy program for individuals who do not have a specific diagnosed
psychiatric illness is not to be considered reasonable and necessary for the treatment of an
illness or injury. Services furnished under such a program are not covered.

Occupational therapy may include vocational and prevocational assessment and training.
When services provided by an occupational therapist are related solely to specific
employment opportunities, work skills, or work settings, they are not reasonable or
necessary for the diagnosis or treatment of an illness or injury and are not covered.
However, A/B MACs (A), (B), and (HHH) exercise care in applying this exclusion,
because the assessment of level of function and the teaching of compensatory techniques
to improve the level of function, especially in activities of daily living, are services which
occupational therapists provide for both vocational and nonvocational purposes. For
example, an assessment of sitting and standing tolerance might be nonvocational for a
mother of young children or a retired individual living alone, but could also be a
vocational test for a sales clerk. Training an amputee in the use of prosthesis for
telephoning is necessary for everyday activities as well as for employment purposes.
Major changes in life style may be mandatory for an individual with a substantial
disability. The techniques of adjustment cannot be considered exclusively vocational or
nonvocational.

230.3 - Practice of Speech-Language Pathology
(Rev. 106, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09)

A. General