Section 68 Occupational Therapy Services FAQs
Q: What are Occupational Therapy Services (OT)?
A: The assessment, planning, and implementation of a program of purposeful activities to develop or maintain adaptive skills necessary to achieve the maximal physical and mental functioning of the individual in the individual’s daily pursuits. OT includes assessment and treatment of individuals whose abilities to cope with the tasks of living are threatened or impaired by developmental deficits, the aging process, learning disabilities, poverty and cultural differences, physical injury or disease, psychological and social disabilities, or anticipated dysfunction. The services must be of such a level, complexity, and sophistication that the judgment, knowledge, and skills of a licensed therapist is required and must be in accordance with acceptable standards of medical practice and be a specific and effective treatment for the child’s condition. The services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law. The prescription must be documented (order/referral form).
Q: Do OT Services have to be “Medically Necessary?”
A: Yes. 
Q: What is “Medically Necessary?”
A: Reasonably necessary and remedial services that are provided in an appropriate setting; recognized as standard medical care based on national standards for best practices and safe, effective, quality care; required for the diagnosis, prevention and/or treatment of illness, disability, infirmity, or impairment and which are necessary to improve, restore, or maintain health and well-being; defined as a covered service; provided by properly qualified practitioners within their scope of practice and are provided within the boundaries of the MaineCare regulations.
Q: Are there particular “settings” in which OT services can be delivered?
A: Yes: All outpatient settings.
Q: Must a “Personalized Plan of Service” be generated for all OT Services?
Q: What is a “Personalized Plan of Service?”
- Type of OT needed; 
- How the service can best be delivered and by whom the service shall be delivered;
- Frequency of services and expected duration of services
- Long and short range goals;
- Plans for coordination with other health service agencies for the delivery of services;
- Splinting supplies for which a physician or primary care provider’s order is necessary;
- Practitioner of the healing arts’ order.
Q: What are the “covered” OT Services?
- Evaluations or re-evaluations
- Therapeutic procedures
- Tests and measurements
- Splinting Supplies
Q: Who can deliver OT?
A: A licensed Occupational Therapist, Registered/Licensed (OTR/L); Occupational Therapist, Licensed (OT/L); Certified Occupational Therapy Assistant, Licensed (COTA/L, “under the supervision of); or an Occupational Therapy Assistant, Licensed (OTA/L, “under the direction of”).
Q: What are OT “Modalities?”
A: Physical agents applied to produce therapeutic changes to biologic tissues including, but not limited to, thermal, acoustic, light, mechanical, or electric energy. Except when performing supervised modalities (by an occupational therapy assistant), the therapist is required to have one-to-one continuous patient contact.
Q: Are “group” OT modalities reimbursable in the school setting?
A: No, it would not appear so.
Q: What are OT “Therapeutic Procedures?”
A: Procedures that cause change through the application of clinical skills and/or services that attempt to improve function. 
Q: Are “group” OT therapeutic procedures reimbursable in the school setting?
Q: Are “group” OT “Tests and Measurements” reimbursable?
A: No, it would not appear so.
Q: What are “Splinting Supplies?”
A: Providers may bill for splinting supplies necessary for the provision of OT. The supplies must be billed at acquisition cost and be documented by an invoice in the child’s file.
Q: Is OT “Co-Therapy” reimbursable?
A: Yes. Provisions in the regulations that prohibited “Co-Therapy” have been removed from the rule. Medical necessity for co-therapy must be documented in the plan of care. The number of units delivered must also be divided amongst the co-therapists.
Q: Are there limits on the amount of reimbursable OT services per day?
A: Yes. 2 hours per day. The occupational therapist cannot seek reimbursement for supervised modalities on any day that modalities requiring constant attendance or any other therapeutic procedures are delivered. Otherwise, supervised modalities as stand-alone treatment are limited to 1 unit per modality per day.
Q: What records are required to be maintained for OT?
- The child’s name, address, birthdate, and MaineCare ID number;
- The child’s social and medical history and medical diagnosis indicating the medical necessity of the services;
- A personalized “plan of service;”  and
- Written progress notes.
Q: What must be documented in the OT written progress notes?
- Identification of the nature, date, and provider of any service given;
- The start time and stop time of the service, indicating the total time spent delivering the service;
- Any progress toward the achievement of established long and short range goals;
- The signature of the service provider for each service provided; and
- A full account of any unusual condition or unexpected event, including the date and time when it was observed and the name of the observer. When services delivered vary from the plan of care, entries must justify why more, less or different care than that specified in the plan of care was provided.
Q: May Schools submit claims for OT services?
A: Public schools are considered just as any other qualified community-based MaineCare provider. Schools are able to re-enroll in MIHMS and bill MaineCare on behalf of the OTs the schools employ. If the OT being utilized by the school is contracted staff, the school district may bill MaineCare as long as the district falls under one of the four models as designated in the Provider Notification of January 20, 2012.
 §68.04, §68.05.
 §68.09-2.3.F., §68.06-5
 §68.06, §68.02-4, §68.09-1.
 Id.; DHHS’ responses to comments during rulemaking, 8/26/10.
 DHHS’ responses to comments during rulemaking, 8/26/10.
 Guidance provided by Kathy Bubar, December 2010; Guidance in CMS Claims Processing Manual.
 Provider Notification from Maine DHHS, 1/20/12.