Robert McDonough, MD Aetna, MC Farmington Ave Hartford, CT Re: Aetna Clinical Policy 0250; Occupational Therapy Services
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1 Occupational Therapy: skills for the Job of Living May Robert McDonough, MD Aetna, MC Farmington Ave Hartford, CT Re: Aetna Clinical Policy 0250; Occupational Therapy Services Dear Doctor McDonough: On behalf of the approximately 35,000 members of the American Occupational Therapy Association, Inc. (AOTA) including occupational therapists who provide services to Aetna members, I am writing to provide comments to the Occupational Therapy Services (0250) Clinical Policy Bulletin (CPB). We have received infonnation from several of our members who provide services to your consumers that the Aetna national CPB lacks the necessary components with regard to the occupational therapy scope of practice and reimbursement direction to make it a comprehensive policy bulletin that serves Aetna's customers who need occupational therapy and their providers. For those reasons, AOTA respectfully requests a review and correction of the current bulletin's policy, and billing and coding provisions as they relate to occupational therapy sefv1ces. While AOTA appreciates the information provided in its introductory policy section about occupational therapy medical necessity based upon Aetna's review, there is not sufficient infonnation contained in the CPB to fully explain the definition and use of occupational therapy services. The guidelines for occupational therapy practice require that occupational therapy providers receive educational training and develop skills and expertise that allow them to provide a multidimensional approach to "patients who experience a disabling condition or who are at risk for these conditions and require assistance to achieve or continue current levels of function" (Moyers, 247). Numerous areas of occupational therapy practice and skilled expertise are absent from the CPB. Furthermore, the CPB does not provide sufficient background information as defined by the profession and reflected in many state laws for medical review. The infonnation and definitions as provided in the CPB are not comprehensive and fail to include many of the central components of the occupational therapy profession; most notably Activities of Daily Living and corresponding HCPCS and ICD-9 codes are absent. The following paragraphs further detail our concerns: The American Occupational Therapy Association, Inc Montgomery Lane Bethesda. MD Fax TDD
2 Aetna's ex lanation 0 the Occu ational Thera Sco e 0 Practice is incom tete / inaccurate. 1. AOTA encourages Aetna to incorporate AOTA's accepted definition ofot practice into the CPB in its entirety. a. AOTA's definition of occupational therapy practice states that "Occupational therapy treatment consists of the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of participation in roles and situations in home, school, workplace, community, and other settings. Occupational therapy services are provided for the purpose of promoting health and wellness and to those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. Occupational therapy addresses the physical, cognitive, psychosocial, sensory, and other aspects of performance in a variety of contexts to support engagement in everyday life activities that affect health, well-being, and quality of life. Treatment modalities and therapeutic procedures may include: IV. v. VI. VII. Vlll. IX X Xl xu X111 Therapeutic use of occupations, exercises, and activities. Application of physical agent modalities, and use of a range of specific therapeutic procedures (such as wound care management; techniques to enhance sensory, perceptual, and cognitive processing; manual therapy techniques) to enhance performance skills. Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices, and orthotic devices, and training in the use of prosthetic devices. Training in self-care, self-management, home management, and community/work reintegration. Development, remediation, or compensation of physical, cognitive, neuromuscular, sensory functions and behavioral skills. Management of feeding, eating, and swallowing to enable eating and feeding performance. Therapeutic use of self, including one's personality, insights, perceptions, and judgments, as part of the therapeutic process. Education and training of individuals, including family members, caregivers, and others. Care coordination, case management, and transition services. Consultative services to groups, programs, organizations, or communities. Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic principles. Assessment, recommendation, and training in techniques to enhance functional mobility, including wheelchair management. Driver rehabilitation and community mobility." (AOTA, 2004 Scope of Practice) 2
3 AOTA has some ave concerns about the remises u on which the medical review criteria or HCPCS fincludinf! CPT) codes and ICD-9 codes contained in the Dolicv are based. 2. AOTA suggests that Aetna use CPT and HCPCS codes consistent with the AOTA scope of practice. a. Common Procedural Terminology (CPT) and Healthcare Common Procedural Coding System (HCPCS) Level II codes are frequently used by occupational therapists in various settings to report services. The CPB currently only mentions four applicable CPT codes (97003, 97004, 97140, and 97535) and three HCPCS codes (GO129, GO152, S9129) that providers may select for coverage of treatment and services. Instructions in the use of CPT codes as noted in the 2006 Current Procedural Terminology Manual-Professional Edition (~2006, American Medical Association), indicate that CPT codes are not discipline specific and that "any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional." HCPCS/CPT codes are appropriately used by more than one profession. For some codes, (e.g. Occupational therapy evaluation), the definitions are consistent and specific to professions. However, for many of the procedure codes, the focus, approach, and specific interventions will vary depending upon which profession is reporting the code. Occupational therapists should not be limited to the use of four codes when their services encompass a much greater range of treatment and interventions. Therefore, the CPB should reflect policy and codes that representhe discipline's full use of the codes for treatment or interventions that are deemed medically necessary per Aetna's consideration. AOTA suggests that the listing of commonly used CPT codes by occupational therapists, provided at the end of this comment letter, be given notable consideration for inclusion into the CPB. AOTA is not attempting to interfere with Aetna's medical necessity criteria but rather to prevent unreasonable restrictions on practice b. AOTA recommends Aetna use of ICD-9 codes be consistent with AOTA scope of practice. The current CPB lists an extremely narrow number of diagnoses that are covered for occupational therapy services. This list includes diagnoses of poliomyelitis, torsion dystonia, Amyotrophic Lateral Sclerosis (ALS), muscular atrophy, Multiple Sclerosis, infantile cerebral palsy, and spina bifida. The need for occupational therapy is not specifically dependent on medical diagnosis, but rather on physical and mental impairments, illnesses, and diseases which result from many conditions. For example, absent from this list are ICD-9 codes that describe diseases, illnesses and conditions seen in a variety of practice settings such as: fractures, low vision disorders, arthritis, stroke, spinal cord injury pain, delayed development, Alzheimer's, mental retardation, cerebrovascular disease, skin ulcers, mood disorders, diseases of 3
4 the musculoskeletal system and connective tissue, lack of coordination, edema, burns, dysphagia etc. Therefore, AOTA suggests that it is inappropriate for an exclusive list to be included in a CPB. If such a list is used, AOTA asks that a statemento the effect that it is not all-inclusive be included and that Aetna provide a procedure whereby additional diagnoses could be considered for coverage as medically necessary. c. AOTA recommends that Aetna eliminate the listing of ICD-9 codes that do not support medical necessity. The current CPB also lists several codes that do not support medical necessity but do support the occupational therapy scope of practice. Therefore, as explained above and also supported by the Centers for Medicare and Medicaid Services (CMS) manual instruction printed below, therapy need is not dependent on medical diagnosis, and therefore, it is wholly inappropriate to provide a narrow list of "non-cover" diagnoses. "While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel." (CMS- Publication , ) services as well as the ~ference materials used to SUDDort the at CPR. 3. AOTA requests that coverage for OT be housed solely in the OT CPR. a. References to occupational therapy contained in the Physical Therapy (PT) Services CPB 0325 should be incorporated into a separate and distinct CPB for occupational therapy. Since there are modalities or procedures used in PT that are also included in the OT scope of practice, consistent with the occupational therapy framework, the OT CPB should make clear that these services are also appropriate within the OT scope of practice. Having references to both professions in the same CPB when two separate ones exist for medical reviewers to consider, creates a confusing situation when attempting to distinguish services provided in one discipline versus another. Additionally, confusion is seen when several codes that are consistent with ICD-9 codes covered and not covered based on medical necessity are found in one CPB and not the other with regards to occupational therapy services. 4. AOTA urges Aetna to update the reference list to include the references attached to reinforce that the CPB is based in OT evidence and research. 8. Accompanying this letter are resources that are directed at providing further evidence that occupational therapy is a valuable service in many areas of.4
5 practice and a benefit to Aetna consumers including The Guide to Occupational Therapy Practice and The Occupational Therapy Framework: Domain and Process. Many of the references currently listed in the CPB continue to be relevant in explaining select areas commonly seen in the practice and scope of occupational therapy. However, there are additional references that are absent which represent areas of occupational therapy practice equally as valuable. AOTA has also created an evidence based literature review that contains both qualitative and quantitative studies covering 11 areas of occupational therapy, including stroke, cerebral palsy, chronic pain, older adults, and children with behavioral and psychosocial needs. Selections taken from AOTA's evidence based literature review series are included as enclosures and references are also accompanied at the end of this letter to serve as an update and addendum to CPB. Clearly, Aetna's national policy generally directs medical reviewers to make medical determinations based on the consumer's individual care needs, and not necessarily fixed criteria. By contrast, this CPB directs reviewer's to determine medical necessity based on limited, narrow, and fixed criteria that are neither current nor reflective of the entire profession. The limitations of this CPB threaten to prevent patients from receiving appropriate and necessary occupational therapy services by setting narrow medically necessary criteria that does not cover the depth and scope of occupational therapy practice. AOTA suggests that Aetna reconsider this recently reviewed CPB in advance of its next annual review cycle. We encourage a re-examination into the integral role occupational therapy providers' play in meeting the complex needs of Aetna's consumer needs. AOTA requests that the strongest consideration be given to these comments. AOTA would be pleased to work with Aetna in any way possible. Please let me know if I can be of further assistance. Sincerely, ~.t~~ } OJ I L" "'~ Tara C. Alexander, OTIL, CPC Health Policy Analyst Reimbursement and Regulatory Policy Enclosures: A complete set (20) of AOTA's Occupational Therapy Practice Guidelines Selected articles from AOTA's Evidence-based Literature Review Series (6) The Guide to Occupational Therapy Practice The Occupational Therapy Practice Framework: Domain and Process AOTA's Official Scope of Practice document AOTA's Use of Codes Document AOTA's Commonly Used CPT codes for Occupational Therapists.5
6 cc: Christina Metzler~ AOTA Associate Executive Director Leslie Stein Lloyd, Director~ Reimbursement and Regulatory Policy Mary Ann Wood~ MSHCM OTR/L~ GRC-OP Therapy Manager Ronnie Schein~ NRH Regional Rehab Development Manager Bcc: Chuck Willmarth Fred Somers Judy Thomas Shannila Sandhu 6
7 References American Occupational Therapy Association. (2004). Scope of practice. American Journal of Occupational Therapy, 58 (November/December), Moyers, P. (1999). The guide to occupational therapy practice. American Journal of Occupational Therapy, 53, '7
8 Suggested reference list illuminating the scope of Occupational Therapy American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, American Occupational Therapy Association. (2004). Scope of practice. American Journal of Occupational Therapy, 58 (November/December), Allen, C., Earhart, C., & Blue, T. (1992). Occupational therapy treatment goals for the physically and cognitively disabled. Rockville, MD: The American Occupational Therapy Association. Bach, D., Bach, M., Bohmer, F., FrOhwald, T., & Grilc, B. (1995). Reactivating occupational therapy: A method to improve cognitive performance in geriatric patients. Age and Aging, 24, Black, M. M., Dubowitz, H., Hutcheson, J., Berenson-Howard, J., & Starr, R. H., Jr. (1995). A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics, 95, Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278, Crepeau, E., Cohn, E., & Schell, B. (Eds.)(2003). Williard & Spackman's occupational therapy. Philadelphia, P A: Lippincott Williams & Wilkins. Gentile, M. (1997). Functional visual behavior, a therapists guide to evaluation and treatment options. Bethesda, MD: The American Occupational Therapy Association. Gutman, S., & Schonfeld, A. (2003). Screening adult neurologic populations. Bethesda, MD: The American Occupational Therapy Association. Law, M., Baum, C., & Dunn, W. (2005). Measuring occupational performance: Supporting best practice in occupational therapy. Thorofare, NJ: Slack Incorporated. Mann, W., & Lane, J. (2005). Assistive technology for persons with disabilities. Bethesda, MD: The American Occupational Therapy Association. Melvin, J., & Jensen, G. (1998). Rheumatologic Rehabilitation Series: Volume i-assessment and Management. Bethesda, MD: The American Occupational Therapy Association. Melvin, J., & Ferrell, K. (2000). Rheumatologic Rehabilitation Series: Volume 2-Adult Rheumatic Diseases. Bethesda, MD: The American Occupational Therapy Association. Melvin, J., & Wright, F.V. (2000). RheumatologicRehabilitation Series: Volume 3-Pediatric Rheumatic Diseases. Bethesda, MD: The American Occupational Therapy Association. Miller-Kuhaneck, H. (2004). Autism: A comprehensive approach, ~ edition. Bethesda, MD: The American Occupational Therapy Association. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, Moyers, P. (1999). The guide to occupational therapy practice. American Journal of Occupational Therapy, 53(3), Neistadt, M. E. (1994). The effects of different treatment activities on functional fine motor coordination in adults with brain injury. American Journal of Occupational Therapy, 48,
9 Salazar, A., Warden, D. L., Schwab, K., Spector, J., Bravennan, S., Walter, J., Cole, R., Rosner, M. M., Martin, E. M., Ecklund, J., & Ellenbogen, R. G. (2000). Cognitive rehabilitation for traumatic brain injury: A randomized trial. JAMA, 283,
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