ࡱ> kmhijq` )bjbjqPqP :|:: g     bbb8:b4nb ggggg$hA ĖNA  gg /V^ g g J gg sPTbpףl0ߣ,Z  p AAp   Vb   b          fb88Care coverage of Occupational Therapy Services is limited. Refer to Chapter II, Section 68.07 for specific limitations. Use the following modifiers when appropriate: TF - Intermediate Level of care used for Certified Occupational Therapy Assistants and priced 10% below the Allowance rate GO - Services delivered under an outpatient therapy plan of care TL - Services delivered under an Individualized Family Service Plan (IFSP) TM - Services delivered under an Individualized Education Plan (IEP) with fb88Care Addendum denoting medical necessity of the service CODESERVICEUNITMAXIMUM ALLOWANCE97003Occupational Therapy Evaluation per evaluation $34.5297004Occupational Therapy Re-evaluation (Ongoing therapy)per session $20.3097150 GOTherapeutic procedure(s), group (2 or more individuals)per member per session$11.51THERAPEUTIC MODALITIES SUPERVISED97012Application of a modality to one or more areas; traction, mechanicalper service$6.2497014Application of a modality to one or more areas; electrical stimulation (unattended)per service $5.6197016Application of a modality to one or more areas; vasopneumatic devicesper service $6.2897018Application of a modality to one or more areas; paraffin bath per service $3.0597022Application of a modality to one or more areas; whirlpoolper service $7.0697024Application of a modality to one or more areas; diathermy (e.g. microwave)per service $2.1097026Application of a modality to one or more areas; infraredper service $1.9497028Application of a modality to one or more areas; ultravioletper service  $2.62 CODESERVICEUNITMAXIMUM ALLOWANCETHERAPEUTIC MODALITIES CONSTANT ATTENDANCE97032Application of a modality to one or more areas; electrical stimulation (manual)15 minutes $6.8897033Application of a modality to one or more areas; iontophoresis15 minutes $9.9097034Application of a modality to one or more areas; contrast baths15 minutes$6.0097035Application of a modality to one or more areas; ultrasound15 minutes $4.8997036Application of a modality to one or more areas; Hubbard tank15 minutes$10.58THERAPEUTIC PROCEDURES97110Therapeutic procedure, one or more areas; therapeutic exercises to develop strength and endurance, range of motion and flexibility15 minutes$11.9397112Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities15 minutes $12.4697113Aquatic therapy with therapeutic exercises15 minutes $14.3497116Gait training (includes stair climbing)15 minutes$10.4697124Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)15 minutes $9.5897140Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions15 minutes $11.15 CODESERVICEUNITMAXIMUM ALLOWANCE97760Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk15 minutes$13.4597761Prosthetic training, upper and/or lower extremities15 minutes $12.0997530Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance)15 minutes $12.6097532Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training,) direct (one-on-one) patient contact by the provider15 minutes $10.3897533Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by provider15 minutes $11.0297535Self/care/home management training (e.g. activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider15 minutes $12.7897542Wheelchair management (eg, assessment, fitting, training)15 minutes $11.67ACTIVE WOUND CARE MANAGEMENT97597Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g. high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instructions(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters per service $23.54  CODESERVICEUNITMAXIMUM ALLOWANCE97598Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g. high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimetersper service$23.5397602Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical applications(s), wound assessment, and instructions(s) for ongoing careper service$16.86TESTS AND MEASUREMENTS97762Check out for orthotic/prosthetic use, established patient15 minutes$13.3197750Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report15 minutes$12.3997755Assistive technology assessment (e.g. to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report15 minutes$14.4492605Evaluation for prescription of non-speech-generating augmentative and alternative communication deviceper evaluation$34.26 92607Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with patient; first hour60 minutes$61.6792608Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with patient; each additional 30 minutes30 minutes $11.91 CODESERVICEUNITMAXIMUM ALLOWANCEMUSCLE AND RANGE OF MOTION TESTING95831Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunkper service $11.3795832Muscle testing, manual (separate procedure) with report; extremity hand, with or without comparison with normal sideper service$10.3895833Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding handsper service $16.0795834Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk total evaluation of body, including hands per service $18.94 95851Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)per service$7.5195852Range of motion measurements and report (separate procedure); each extremity hand, with or without comparison with normal sideper service$5.84CENTRAL NERVOUS SYSTEM ASSESSMENTS/TESTS (e.g. NEURO-COGNITIVE, MENTAL STATUS, SPEECH TESTING)96110Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen) with interpretation and reportper service $4.6496111Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen) with interpretation and report extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and reportper service $56.39     10-144CH. 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 68 OCCUPATIONAL THERAPY SERVICES LAST UPDATED 06/29/12  PAGE 5 10-144CH. 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 68 OCCUPATIONAL THERAPY SERVICES LAST UPDATED 06/29/12 Effective 06/29/12 Effective 06/29/12 Effective 06/29/12 Effective 06/29/12 Effective 06/29/12 }' - i n : ; 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