Occupational Therapy Services AHM

Transcription

1 Occupatinal Therapy Services AHM Clinical Indicatins Occupatinal Therapy in an utpatient setting is cnsidered medically necessary when ALL f the fllwing Physician has rdered ccupatinal therapy and dcumentatin includes the nature and nset f symptms, diagnsis, r injury requiring ccupatinal therapy and 1 r mre f the fllwing situatins apply: ACUTE IMPAIRMENT- ALL f the fllwing must be met The patient has dcumented acute functinal impairment(s) as a result f disease, trauma, r surgery, r as a result f a recent change in a pre-existing cnditin that has the expectatin that the impairments will imprve with therapy [A] Examples f chrnic cnditins- multiple sclersis, cerebral palsy, pli, spina bifida and amytrphic lateral sclersis (Lu Gehrig's disease) Functinal impairment must affect the activities f daily living (ADL s) f the patient and be a change frm the patients baseline prir t injury r impairment [B] OTHER DISORDERS- Must meet ALL f the fllwing requirements Physician has rdered ccupatinal therapy fr a member with cngenital disrder r ther disrders such as autism AND there is a benefit fr therapy fr members with this diagnsis [C] Functinal impairment must affect the activities f daily living (ADLs) f the patient ALL f the fllwing cnditins apply: Patient's medical r surgical cnditin is stable t allw participatin in OT Patient demnstrates the necessary ability t participate and make prgress in OT(demnstrates mtivatin and cmpliance with prescribed plan f care) Written Dcumentatin frm the prvider cntaining a minimum f 1 r mre f the fllwing Abnrmal muscle tne r reflexes Amputatin Cgnitive, Sensry r Expressive deficit such as any 1 r mre f the fllwing Limited sight/visual deficits Perceptual-Mtr deficits Self-care deficits (dcument specific details in ntes) Incapacitating pain r spasm in upper extremity with ALL f the fllwing [D] The pain r spasm must prevent the patient frm perfrming activities f daily living relative t prir capability AC-AEOCC Page 1 f 10

2 Myfascial pain - Treatment shuld include sft tissue mbilizatin r trigger pint release technique with stretching and aggressive hme stretching prgram. Muscle weakness r paralysis Mtr deficits Skeletal trauma r defrmity Limited Range f Mtin (ROM) [E] Nerve r tendn damage t hand r arm Failure t thrive (Check Plan benefit language and terms) [F] Develpmental delay-assess medical apprpriateness f ccupatinal therapy (degree f delay and impact n ADL's and functinal abilities) [G] Learning disability (Check plan benefit language and terms) [H] TREATMENT GOALS-PLAN OF CARE - ALL f the fllwing is required: Written dcumentatin frm the prvider cntaining specific and reasnable gals in measurable terms within a pre-set defined time perid Gals are realistic and achievable. Must be gal riented, tward independent functining. Occupatinal therapy shrt-term gals shuld be re-evaluated and re-set regularly, and thereafter, 5-6 treatments (r after the initial 2 weeks). Cncurrent review can then ccur after 4 mre weeks r after 8-12 treatments if the patient meets the criteria t cntinue with the therapy Written dcumentatin frm the prvider cntaining specific treatment plan, including hme treatment, within a pre-set defined time perid This shuld change ver time. Treatment plan usually includes hme assignments, exercises, ADL tasks, and wrk with a significant ther that encurages the patient t -D fr self. Suggest reassessment at the midpint f therapy plan t determine prgress. Fllwing dcumentatin shuld als include the patient and caregiver s cmpliance with the hme exercise r activity plan. THIS is a majr key t determine the success f the prgram TYPES OF THERAPY - Written dcumentatin frm the prvider shuld cntain 1 r mre f the fllwing, but, usually nt mre that 3 types f therapy at ne time: Cgnitive Training Hydrtherapy-elbw [I] Jint prtectin Range f Mtin (ROM) Manual exercise- Active resistive, muscle re-educatin, crdinatin Measuring, fabricating r training in use f medically necessary prescribed equipment [J] Oral-mtr training Perceptive training Pre-vcatinal evaluatin and r training Check fr Disability and/r Wrkman s Cmp benefits Restratin f ADLs AC-AEOCC Page 2 f 10

3 Dcument in ntes, specific ADLs being addressed, e.g., dressing, cking, hygiene, feeding, hmemaking, banking, shpping, etc Nte: Driver training is nt cnsidered treatment f disease because driving an autmbile is nt a basic activity f daily living. Sensry re-educatin Wrk simplificatin and r energy cnservatin Paraffin [K] Electrical stimulatin [L] INDICATIONS FOR CONTINUED THERAPY -OP Occupatinal Therapy shuld be cntinued when ALL f the fllwing apply: Member has 1 r mre f the fllwing ACUTE IMPAIRMENT- must meet ALL f the fllwing The patient has dcumented acute functinal impairment(s) as a result f disease, trauma, r surgery, r as a result f a recent change in a pre-existing cnditin that has the expectatin that the impairments will imprve with therapy [M] Functinal impairment must affect the activities f daily living (ADL s) f the patient and be a change frm the patient s baseline prir t injury r impairment NOTE: Many cmmercial plans d nt have ccupatinal therapy as a benefit fr patients with cngenital, r neurmuscular disrders that are nt expected t imprve ver time. Check plan benefits. If there is n exclusin, prceed thrugh the guideline. OTHER DISORDERS- Must meet ALL f the fllwing Physician has rdered ccupatinal therapy fr a member with cngenital disrder r ther disrders such as autism AND there is a benefit fr therapy fr members with this diagnsis [N] Functinal impairment must affect the activities f daily living (ADLs) f the patient. Member has nt achieved gals set by licensed skilled therapist and physician Member is making measurable prgress twards gals Member has nt reached the realistic maximal functinal capability f their specific cnditin Therapy is nt maintenance in nature Therapy is nt fr the member's cnvenience, nr is it custdial r fr educatinal purpses Member cannt perfrm therapy independently (Interventin by a skilled prfessinal is required) Required dcumentatin includes: Dcumented prgress twards reaching the functinal gals as demnstrated in the cmparisn f the initial evaluatin t the current evaluatin Any barriers encuntered and/r extenuating circumstances that have prevented the member frm reaching gal during the initially apprved number f visits The realistic ptential fr member t reach set gal The reasn why a HEP (hme exercise prgram) cannt be established vs cntinuing with ne-nne skilled therapist treatment AC-AEOCC Page 3 f 10

4 INDICATIONS TO DISCONTINUE THERAPY-OP Occupatinal Therapy shuld be discntinued when 1 r mre f the fllwing apply: Achievement f anticipated gals and desired utcmes Patient r caregiver declines t cntinue Inability t make sustained prgress tward gals due t medical r psychscial cnditins Therapies n lnger benefit patient fr 1 r mre f the fllwing Patient prgress has reached plateau r maximum medical imprvement has been achieved Cntinued therapy is maintenance in nature Cntinued therapy is fr cnvenience f patient nly/custdial in nature Patient can cntinue independently (interventin by skilled prfessinal is n lnger needed) Evidence Summary Backgrund Occupatinal therapy is a health care service that invlves the use f purpseful activities t help peple regain perfrmance skills lst thrugh injury r illness. Individual prgrams are designed t imprve quality f life by recvering cmpetence, maximizing independence, and prevent injury r disability as much as pssible, s that a persn can cpe with wrk, hme, and scial life. Occupatinal therapy services emphasize useful and purpseful activities t imprve neurmusculskeletal functin and t prvide training in activities f daily living (ADL), including feeding, dressing, bathing, and ther self-care activities. Other ccupatinal therapy services include the design, fabricatin and use f rthses, and guidance in the selectin and use f adaptive equipment. Occupatinal therapy is cnsidered medically necessary nly when prvided t achieve a specific diagnsis-related gal as dcumented in the plan f care. Occupatinal therapy shuld: 1) meet the functinal needs f a patient wh suffers frm physical disability; 2) achieve a specific diagnsis-related gal fr a patient wh has a reasnable expectatin f achieving measurable imprvement in a reasnable and predictable perid f time; 3) be specific, effective and reasnable treatment fr the patient's diagnsis and physical cnditin; and 4) be delivered by a qualified prvider f ccupatinal therapy services (i.e., ne wh is licensed, where required, and is perfrming within the scpe f license). Accrding t the American Occupatinal Therapy Assciatin (2002), ccupatinal therapists wrk with adults and children acrss the lifespan wh may suffer frm physical, develpmental r psychlgical impairments. Hffmann and clleagues (2011) examined if ccupatinal therapy imprves functinal perfrmance f basic ADL and specific cgnitive abilities in peple wh have cgnitive impairment after strke. In this review, randmized cntrlled trilas and quasi-rcts that evaluated an ccupatinal therapy interventin fcused n prviding cgnitive retraining t adults with clinically defined strke and cnfirmed cgnitive impairment were included. Searches up t April 2009 were cnducted in: the Cchrane Strke Grup AC-AEOCC Page 4 f 10

5 Trials Register, the Cchrane Central Register f Cntrlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, PsycBITE, OTseeker, and Dissertatin Abstracts. The search als included a review f the reference lists f relevant studies, a hand-search f relevant ccupatinal therapy jurnals, and cntact with key researchers in the area. Tw review authrs independently examined the abstracts that might meet the inclusin criteria, assessed the methdlgical quality, and extracted data. Of 17 trials that appeared t be relevant and were reviewed in full text, nly 1 trial (n = 33) was finally included in this review. The study was an RCT f cgnitive skills remediatin training and there was n difference between grups fr the 2 utcmes that were relevant t this review that were measured: imprvement in time judgement skills and imprvement in basic ADLs n the Barthel Index. The effectiveness f ccupatinal therapy fr cgnitive impairment pst-strke remains unclear. The ptential benefits f cgnitive re-training delivered as part f ccupatinal therapy n imprving basic daily activity functin r specific cgnitive abilities, r bth, f peple wh have had a strke can nt be supprted r refuted by the evidence included in this review. The authrs stated that mre research is required. Spilitpulu and Atwal (2012) nted that althugh ccupatinal therapists are integral t the rehabilitatin prcess f peple with amputatins, the effectiveness f the ccupatinal therapy interventin fr lder adults with lwer limb amputatins has nt been investigated. These researchers examined the effectiveness f the ccupatinal therapy interventins with lder adults aged 65 years and lder with lwer limb amputatins. A systematic search was cnducted in CINAHL, PUBMED, OTSEEKER and OTDBASE frm January 1985 t January The eligible papers were critiqued using a typlgy, which invlved designatin f levels f evidence and quality markers. The databases yielded 2,664 ptential publicatins. Of these, nly 2 were included in the final review. These studies suggested that the frequency f the ccupatinal therapy sessins was fund t be statistically significantly related t prsthesis use and that service users perceived psitive benefits abut the prvisin f stump bards. Bth studies had limitatins resulting in a need fr further investigatin in these areas. The authrs cncluded that research evidence n the ccupatinal therapy interventins with this ppulatin is limited and scarce. They stated that ccupatinal therapists need t take urgent actin t address the identified evidence-based gaps in rder t devise infrmed targeted rehabilitatin prgrams fr this client grup. This systematic review has cntributed t the understanding f the ccupatinal therapy practice in the rehabilitatin f lder adults with lwer limb amputatins. It has highlighted gaps in evidence that ccupatinal therapists need t address urgently in rder t infrm their rehabilitatin prgrams with this client grup. In a meta-analysis, Kim and clleagues (2012) examined effects f ccupatinal therapy based n sensry stimulatin, envirnmental mdificatin and functinal task activity n the behaviral prblems and depressin f individual with dementia. These investigatrs perfrmed an extensive search in database such as MEDLINE, CINAHL, PrQuest Medical Library, and Cchrane and ccupatinal therapy-related 11 jurnals. Tw reviewers independently identified studies, extracted data, evaluated methdlgical AC-AEOCC Page 5 f 10

6 quality f the studies. Effect size was estimated using standardized mean difference with 95 % cnfidence intervals (CI). Significant hetergeneity and publicatin bias were investigated. A ttal f 9 studies including 751 peple were selected. Sensry stimulatin was effective interventin in imprving behaviral prblems (0.32; 95 % CI: 0.04 t 0.59). The authrs cncluded that this review identified that ccupatinal therapy based n sensry stimulatin was effective in imprving behaviral prblems. Hwever, they stated that the number f studies included in this review was limited; mre research is needed t enable evidence-based ccupatinal therapy fr dementia patients. Spilitpulu and Atwal (2012) stated that althugh ccupatinal therapists are integral t the rehabilitatin prcess f peple with amputatins, the effectiveness f the ccupatinal therapy interventin fr lder adults with lwer limb amputatins has nt been investigated. These investigatrs examined the effectiveness f the ccupatinal therapy interventins with lder adults aged 65 years and lder with lwer limb amputatins. A systematic search was cnducted in CINAHL, PUBMED, OTSEEKER and OTDBASE frm January 1985 t January The eligible papers were critiqued using a typlgy, which invlved designatin f levels f evidence and quality markers. The databases yielded 2,664 ptential publicatins. Of these, nly 2 were included in the final review. These studies suggested that the frequency f the ccupatinal therapy sessins was fund t be statistically significantly related t prsthesis use and that service users perceived psitive benefits abut the prvisin f stump bards. Bth studies had limitatins resulting in a need fr further investigatin in these areas. The authrs cncluded that research evidence n the ccupatinal therapy interventins with this ppulatin is limited and scarce. They stated that ccupatinal therapists need t take urgent actin t address the identified evidence-based gaps in rder t devise infrmed targeted rehabilitatin prgrams fr this client grup. References 1. McCrmack GL. The rle f ccupatinal therapy in hme care. Hme Care Prvid. 1997;2(1): Myers PA. The guide t ccupatinal therapy practice. American Occupatinal Therapy Assciatin. Am J Occup Ther. 1999;53(3): American Occupatinal Therapy Assciatin. Standards f practice fr ccupatinal therapy. Am J Occup Ther. 1994;48(11): Schultz-Krhn W, Cara E. Occupatinal therapy in early interventin: Applying cncepts frm infant mental health. Am J Occup Ther. 2000;54(5): Sulch D, Perez I, Melburn A, et al. Randmized cntrlled trial f integrated (managed) care pathway fr strke rehabilitatin. Strke. 2000;31(8): Smith RO. The rle f ccupatinal therapy in a develpmental technlgy mdel. Am J Occup Ther. 2000;54(3): AC-AEOCC Page 6 f 10

7 7. Harklerad A, Schirf D, Vlpe J, et al. Critical pathway develpment: An integrative literature review. Am J Occup Ther. 2000;54(2): Nrani HZ, Brady B, McGahan L, et al. Strke rehabilitatin services: Systematic reviews f the clinical and ecnmic evidence. Technlgy Reprt N. 35. Ottawa, ON: Canadian Crdinating Office fr Health Technlgy Assessment (CCOHTA); Trmbly CA, Ma HI. A synthesis f the effects f ccupatinal therapy fr persns with strke. Part I: Restratin f rles, tasks, and activities. Am J Occup Ther. 2002;56(3): Ma HI, Trmbly CA. A synthesis f the effects f ccupatinal therapy fr persns with strke. Part II: Remediatin f impairments. Am J Occup Ther. 2002;56(3): Bilney B, Mrris ME, Perry A. Effectiveness f physitherapy, ccupatinal therapy, and speech pathlgy fr peple with Huntingtn's disease: A systematic review. Neurrehabil Neural Repair. 2003;17(1): Hammnd A, Yung A, Kida R. A randmised cntrlled trial f ccupatinal therapy fr peple with early rheumatid arthritis. Ann Rheum Dis. 2004;63(1): Steultjens EM, Dekker J, Buter LM, et al. Occupatinal therapy fr children with cerebral palsy: A systematic review. Clin Rehabil. 2004;18(1): Jain S, Dawsn J, Quinn NP, Playfrd ED. Occupatinal therapy in multiple system atrphy: A pilt randmized cntrlled trial. Mv Disrd. 2004;19(11): Steultjens EEMJ, Buter LLM, Dekker JJ, et al. Occupatinal therapy fr rheumatid arthritis. Cchrane Database Syst Rev. 2004;(1):CD Steultjens EMJ, Dekker J, Buter LM, et al. Occupatinal therapy fr multiple sclersis. Cchrane Database Syst Rev. 2003;(3):CD Dixn L, Duncan D, Jhnsn P, et al. Occupatinal therapy fr patients with Parkinsn's disease. Cchrane Database Syst Rev. 2007;(3):CD Mrris ME, Perry A, Bilney B, et al. Outcmes f physical therapy, speech pathlgy, and ccupatinal therapy fr peple with mtr neurn disease: A systematic review. Neurrehabil Neural Repair. 2006;20(3): Legg LA, Drummnd AE, Langhrne P. Occupatinal therapy fr patients with prblems in activities f daily living after strke. Cchrane Database Syst Rev. 2006;(4):CD Legg L, Drummnd A, Lenardi-Bee J, et al. Occupatinal therapy fr patients with prblems in persnal activities f daily living after strke: Systematic review f randmised trials. BMJ. 2007;335(7626): West C, Bwen A, Hesketh A, Vail A. Interventins fr mtr apraxia fllwing strke. Cchrane Database Syst Rev. 2008;(1):CD Hffmann T, Bennett S, Kh C, McKenna K. The Cchrane review f ccupatinal therapy fr cgnitive impairment in strke patients. Eur J Phys Rehabil Med. 2011;47(3): Spilitpulu G, Atwal A. Is ccupatinal therapy practice fr lder adults with lwer limb amputatins evidence-based? A systematic review. Prsthet Ortht Int. 2012;36(1): Brwn C. Occupatinal therapy practice guidelines fr adults with serius mental illness. Bethesda, MD: American Occupatinal Therapy Assciatin, Inc. (AOTA); AC-AEOCC Page 7 f 10

8 25. Kim SY, Y EY, Jung MY, et al. A systematic review f the effects f ccupatinal therapy fr persns with dementia: A meta-analysis f randmized cntrlled trials. NeurRehabilitatin. 2012;31(2): Appendix The fllwing care plan is required t dcument the medical necessity f ccupatinal therapy: Occupatinal therapy must be prvided in accrdance with an nging, written plan f care. The purpse f the written plan f care is t assist in determining medical necessity. The plan f care must include sufficient infrmatin t determine the medical necessity f treatment. The plan f care must be specific t the diagnsis, presenting symptms, and findings f the ccupatinal therapy evaluatin. The plan f care must be signed by the member's attending physician and ccupatinal therapist. The plan f care shuld include ALL f the fllwing A reasnable estimate f when the gals will be reached Quantitative bjectives Specific statements f lng-term and shrt-term gals The date f nset r exacerbatin f the disrder/diagnsis The frequency and duratin f treatment The specific treatment techniques and/r exercises t be used in treatment. The plan f care shuld be nging (i.e., updated as the member's cnditin changes) and treatment shuld demnstrate reasnable expectatin f imprvement (as defined belw): The member shuld be re-evaluated regularly, and there shuld be dcumentatin f prgress made tward the gals f ccupatinal therapy. The treatment gals and subsequent dcumentatin f treatment results shuld specifically demnstrate that ccupatinal therapy services are cntributing t such imprvement. Reviewed by a Bard Certified Internist Reviewed by David Evans, MD, Medical Directr, Active Health Management- June 2016 ACTIVEHEALTH MANAGEMENT. Ftntes [A] Cverage is typically excluded fr services, treatment, educatin testing, r training related t learning disabilities r develpmental delays. When the plicy has such an exclusin, ccupatinal therapy is nt cvered when the primary r the nly diagnsis fr a member is mental retardatin r a learning disability such as a perceptual handicap, brain AC-AEOCC Page 8 f 10

9 damage nt caused by accidental injury r illness, minimal brain dysfunctin, dyslexia, r develpmental delay. [ A in Cntext Link 1 ] [B] Driver training is nt cnsidered treatment f disease because driving an autmbile is nt a basic activity f daily living. [ B in Cntext Link 1 ] [C] In additin t use in nn-chrnic cnditins and acute illnesses, a rle fr ccupatinal therapy has been prpsed in the management f certain chrnic diseases. It may be used t slw r prevent further deteriratin f bdy functin impaired by a neurlgical disease such as multiple sclersis, cerebral palsy, pli, spina bifida and amytrphic lateral sclersis (Lu Gehrig's disease). Mst Aetna plicies limit cverage f ccupatinal therapy t nnchrnic cnditins and acute illnesses. [ C in Cntext Link 1 ] [D] Other HMO and PPO and Indemnity plans have different benefits fr ccupatinal therapy. In sme cases the benefits are defined by a ttal number f sessins cvered per year. In ther benefit designs, ccupatinal therapy may be cvered as an unlimited benefit as lng as it is dcumented that the member is prgressing twards a gal. Cnsult the specific certificates f cverage fr details f plan benefits. [ D in Cntext Link 1 ] [E] Occupatinal therapy may require precertificatin in sme plan designs. Subject t plan benefit descriptins, cverage f ccupatinal therapy may be limited. In many f ur HMO plans the benefit is limited t a 60-day treatment perid. In these plans, the treatment perid f 60 days applies t a specific cnditin. Once the 60-day treatment perid expires, n additinal ccupatinal therapy benefits will be prvided fr that cnditin during the cntract year. Hwever, it is pssible fr a member t receive mre than ne 60-day treatment curse f ccupatinal therapy per year as treatment f separate cnditins. [ E in Cntext Link 1 ] [F] Fr example, a surgical prcedure causing the need fr ccupatinal therapy is cnsidered t be the initiatin f a new r separate cnditin in a persn wh previusly received ccupatinal therapy fr anther indicatin, and s qualifies the member t receive cverage fr an additinal curse f ccupatinal therapy as utlined abve. An exacerbatin r flare-up f a chrnic illness is nt cnsidered t be a new incident f illness. [ F in Cntext Link 1 ] Cdes CPT r HCPCS: 97003, 97004, 97140, 97535, G0129, G0152, G0158, G0160, S9129 AC-AEOCC Page 9 f 10

10 ICD-9 Diagnsis: , , , , 045.1, , , , , 045.2, , , , , 045.9, , , , , 138, 314.1, , , , , , , 741.9, , , , AC-AEOCC Page 10 f 10