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Occupational Therapy

Occupational Therapy shall mean medically necessary diagnostic, therapeutic, and corrective services which are within the scope of state licensure and which are provided to assess and treat functional limitations involving performance of activities of daily living; and the initial training of provider staff on the appropriate implementation of the therapy plan of care. 

Occupational Therapy services provided to improve or maintain current functional abilities as well as prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition.  Services must be provided by a licensed occupational therapist or by a licensed occupational therapist assistant working under the supervision of a licensed occupational therapist.  Occupational Therapy must be ordered by a physician, physician assistant, or nurse practitioner and must be provided face to face with the waiver participant except for that portion of the assessment involving development of the plan of care.  Occupational Therapy therapeutic and corrective services shall not be ordered concurrently with Occupational Therapy assessments (i.e., assess and treat orders are not accepted).

Occupational Therapy shall be provided in accordance with a treatment plan developed by a licensed occupational therapist based on a comprehensive assessment of the waiver participant’s needs and shall include specific functional and measurable therapeutic goals and objectives.  The goals and objectives shall be related to provision of Occupational Therapy to prevent or minimize deterioration involving a chronic condition which would result in further loss of function.  Continuing approval of Occupational Therapy services shall require documentation of reassessment of the waiver participant’s condition and continuing progress of the waiver participant toward meeting the goals and objectives.

Occupational Therapy shall not be billed when provided during the same time period as Physical Therapy; Speech, Hearing, and Language Services; Nutrition Services, Orientation and Mobility Services for Impaired Vision, or Behavior Services, unless there is documentation in the waiver participant’s record of medical justification for the two services to be provided concurrently.   Occupational Therapy is not intended to replace services that would normally be provided by direct care staff.

Occupational Therapy services are not intended to replace services available through the Medicaid State Plan/TennCare Program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act.  To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service.  Occupational Therapy shall not be covered for children under age 21 years (since it would duplicate TennCare/EPSDT benefits).

The unit of reimbursement for an Occupational Therapy assessment with plan development shall be per day.  The unit of reimbursement for other Occupational Therapy services shall be per 15 minutes.

Reimbursement for an Occupational Therapy assessment with development of an Occupational Therapy plan based on such an assessment shall be limited to a maximum of one assessment with plan development per month with a maximum of 3 assessments per year per waiver participant per provider.  Occupational Therapy services other than such assessments (e.g., waiver participant-specific training of caregivers; provision of therapeutic services; monitoring progress) shall be limited to a maximum of 1.5 hours per waiver participant per day. 

Occupational Therapy assessments shall not be billed on the same day with other Occupational Therapy services.  Reimbursement shall not be made for telephone consultations.  A provider shall not receive reimbursement for Occupational Therapy unless provided by a licensed occupational therapist or by a licensed occupational therapist assistant working under the supervision of a licensed occupational therapist.

Applicable limits, if any, on the amount, frequency, or duration of this service:

  • 1 assessment with plan development per month.
  • 3 assessments per year per provider.
  • 1.5 hours per day for services other than assessments.

 

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