Assessment

40.2.4.1 - Assessment (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) Assuming all other eligibility and coverage requirements are met, the skills of an occupational therapist to assess and reassess a patient's rehabilitation needs and potential or to develop and/or implement an occupational therapy program are covered when they are reasonable and necessary because of the patient's condition. As described in §40.2.1(b), at defined points during a course of therapy, the qualified occupational therapist (instead of an assistant) must perform the ordered therapy service visit, assess the patient’s function using a method which allows for objective measurement of function and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patient’s clinical record. Refer to §40.2.1(b) for specific timing and documentation requirements associated with these requirements.