Clinical UM Guideline |
Subject: Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services | |
Guideline #: CG-REHAB-10 | Publish Date: 04/10/2024 |
Status: Reviewed | Last Review Date: 02/15/2024 |
Description |
This document provides clinical criteria for the use of outpatient physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care. Provision of these services in other settings is not addressed in this document.
Note: Please see the following related documents for additional information:
Clinical Indications |
Note: The medical necessity of physical therapy, occupational therapy, and speech-language pathology services requested may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient site of care for physical or occupational therapy services, or speech-language pathology services.
Medically Necessary:
Outpatient physical therapy, occupational therapy, and speech-language pathology services provided in the hospital outpatient department or hospital outpatient clinic site of care is considered medically necessary when any of the following conditions is present:
Not Medically Necessary:
Physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care are considered not medically necessary, for all other indications, including when criteria above have not been met.
Coding |
Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
Discussion/General Information |
A wide variety of settings may be used to provide physical therapy, occupational therapy, and speech-language pathology services, including hospitals, private practices, outpatient clinics, nursing homes and rehabilitation facilities, and in the home. The location of services is determined by many factors, including the physical and medical condition of the individual receiving treatment, the need for specialized equipment or personnel, and the location of the individual in relation to the needed services. Safety is a major concern, and the location in which services are provided should be adequately resourced and staffed to address any potential medical needs that may arise during a treatment session.
References |
Government Agency, Medical Society, and Other Authoritative Publications:
History |
Status | Date | Action |
Reviewed | 02/15/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised References section. |
Reviewed | 02/16/2023 | MPTAC review. Updated References section. |
Reviewed | 02/17/2022 | MPTAC review. Updated References section. |
Revised | 02/11/2021 | MPTAC review. Title changed to: Site of Care: Outpatient Physical therapy, Occupational Therapy, and Speech-Language Pathology Services. Changed wording to "site of care" from "level of care" throughout document. Updated References section. |
Reviewed | 02/20/2020 | MPTAC review. Updated References section. |
Reviewed | 03/21/2019 | MPTAC review. Updated References section. |
Reviewed | 03/22/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section. |
New | 05/04/2017 | MPTAC review. Initial document development. |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.