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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-97000-04

Original Effective Date: 05/15/01

Reviewed: 06/25/15

Revised: 07/15/15

Subject: Cognitive Rehabilitation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem solving, and executive functions. Cognitive rehabilitation consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems.

Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist; in the hospital, physician office or clinic, or at home.

Duration and intensity of cognitive rehabilitation therapy programs vary. One approach for comprehensive cognitive rehabilitation is a 16-week outpatient program consisting of 5 hours of therapy a day, 4 days a week. In this approach, cognitive group treatment occurs for three 2-hour sessions each week and three 1-hour individual sessions (total of 9 hours per week). Cognitive rehabilitation programs for specific defects, e.g., memory training, are less intensive and generally have 1 or 2 sessions (30 or 60 minutes) per week for 4 to 10 weeks.

Cognitive rehabilitation must be distinguished from occupational therapy (CPT codes 97535–97537); occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop the memory, language, and reasoning skills that can then be applied to specific environments, as described by the occupational therapy codes.

Sensory integration therapy may be considered a component of cognitive rehabilitation therapy. Sensory integration therapy is discussed in MCG#01-97000-03.

POSITION STATEMENT:

Cognitive rehabilitation as a distinct and definable component of the rehabilitation process meets the definition of medical necessity in the rehabilitation of individuals with traumatic brain injury or brain injury due to cerebrovascular accident (stroke), intracranial aneurysm, anoxia, encephalitis, brain tumors, or brain toxins when ALL of the following conditions are met:

When one or more of the above conditions is not met, then cognitive rehabilitation is considered experimental or investigational, as there is insufficient evidence to support conclusions regarding effects on net health outcomes.

Cognitive rehabilitation is experimental or investigational for all other applications, including but not limited to, concussion/post-concussion syndrome, attention deficit disorder, attention deficit hyperactivity disorder, developmental delay, learning disabilities, prematurity, Parkinson’s disease, multiple sclerosis, cerebral palsy, schizophrenia, pervasive developmental disorders/autism spectrum disorders, and the aging population, including individuals with Alzheimer’s disease and other dementias. There is insufficient evidence in the published peer-reviewed literature to validate the effectiveness of cognitive rehabilitation as either an isolated component or one component of a multimodal rehabilitation program for these conditions.

BILLING/CODING INFORMATION:

CPT Coding

97532

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, radiology studies, and operative report (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Surgical report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT and PROGRAM EXCEPTIONS.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Therapy and Rehabilitation Services (L29289) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Sensory Integration Therapy, 01-97000-03

OTHER:

None applicable.

REFERENCES:

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  2. Agency for Health Care Policy & Research (AHCPR). U.S. Department of Health and Human Services. Evidence Report/Technology Assessment: Number 2. (1998). “Rehabilitation for Traumatic Brain Injury Summary”, (AHCPR Pub. No. 99-E005).
  3. Agency for Health Care Policy & Research (AHCPR). U.S. Department of Health and Human Services. Evidence Report 2, Supplement. (1998). “Rehabilitation for Traumatic Brain Injury in Children and Adolescents”, (AHCPR Pub No. 99-E025).
  4. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7713. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Apr. (Accessed 05/31/13)
  5. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8108. Clinical guidelines for stroke management 2010: Rehabilitation. Melbourne (Australia): National Stroke Foundation; 2010 Sep. p. 78-95. (Accessed 06/01/13).
  6. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8509. Clinical practice guidelines for psychosocial interventions in severe mental illness. Madrid: Quality Plan for the National Health System, Ministry of Health and Social Policy, Aragon Health Sciences Institute (I+CS); 2009.
  7. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8628. Clinical practice guideline for schizophrenia and incipient psychotic disorder. Madrid (Spain): Quality Plan for the National Health System of the Ministry of Health and Consumer Affairs, Catalan Agency for Health Technology Assessment and Research; 2009 Mar.
  8. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8250. VA/DoD clinical practice guideline for the management of stroke rehabilitation. Management of Stroke Rehabilitation Working Group. Washington (DC): Veterans Health Administration, Department of Defense; 2010. (Accessed 05/31/13).
  9. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7509. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009.
  10. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8616. Cross-continuum topics in stroke management. In: Canadian best practice recommendations for stroke care. Canadian best practice recommendations for stroke care. Ottawa (ON): Canadian Stroke Network; 2010 Dec 8.
  11. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8842. Best evidence statement (BESt). Speech therapist directed use of computer assisted cognitive rehabilitation (CACR) for patients with acquired brain injury. Cincinnati Children's Hospital Medical Center; 2011 Sep 13.
  12. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9702. Brain injury rehabilitation in adults. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN); 2013 Mar.
  13. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9955: Stroke rehabilitation. Long-term rehabilitation after stroke. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Jun.
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  15. Blue Cross Blue Shield Association Medical Policy Reference Manual. 8.03.10 Cognitive Rehabilitation, (March 2014).
  16. Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Cognitive Rehabilitation for Traumatic Brain Injury in Adults. TEC Assessments 2002, Volume 17, No. 20.
  17. Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Cognitive Rehabilitation for Traumatic Brain Injury in Adults. Volume 23, No. 3, May 2008. (Accessed 05/27/14).
  18. Bowen A, Lincoln NB, Dewey M. Cognitive rehabilitation for spatial neglect following stroke. The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586. (Updated 07/04/05).
  19. Cappa SF, Benke T, Clarke S, Rossi B, Stemmer B, van Heugten CM; Task Force on Cognitive Rehabilitation; European Federation of Neurological Societies. EFNS guidelines on cognitive rehabilitation: report of an EFNS task force. Eur J Neurol. 2005 Sep; 12(9): 665-80.
  20. Ceravolo MG. Cognitive rehabilitation of attention deficit after brain damage: from research to clinical practice. Eura Medicophys. 2006 Mar; 42(1): 49-51.
  21. Chiaravalloti ND, Genova HM, DeLuca J. Cognitive rehabilitation in multiple sclerosis: the role of plasticity. Front Neurol. 2015 Apr 2;6:67.
  22. Cicerone KD et al. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil. 2005 Aug;86(8):1681-92. (Accessed 06/22/14)
  23. Cicerone KD, et. al. Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008. Arch Phys Med Rehabil Vol 92, April 2011. (Accessed 06/22/14)
  24. Cicerone KD, et al. Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice. Arch Phys Med Rehabil Vol 81, December 2000.
  25. Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector A. Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003260. DOI: 10.1002/14651858.CD003260. (Updated 09/04/06).
  26. ClinicalTrials.gov. NCT00166348. Does Cognitive Rehabilitation Demonstrate Benefits in the Group Setting With People Whom Have Experienced Brain Injury? Mayo Clinic. Last updated 01/19/10.
  27. ClinicalTrials.gov. NCT01207856. Randomised Controlled Clinical Trial of Cognitive Rehabilitation in Multiple Sclerosis (REACTIV). University Hospital, Bordeaux. Last updated 05/05/11.
  28. ClinicalTrials.gov. NCT01339806. The Study of Cognitive Rehabilitation Effectiveness for Mild Traumatic Brain Injury (SCORE). The Defense and Veterans Brain Injury Center Henry M. Jackson Foundation for the Advancement of Military Medicine. Last updated 07/07/11.
  29. Connolly ES, et. al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2012;43:1711-1737.
  30. DeLuca J. Processing Speed versus Working Memory: Contributions to an Information Processing Task in Multiple Sclerosis. Appl Neuropsychol Adult. 2012 April ; 19(2): 132–140.
  31. Duncan PW, Zorowitz R, et al. Management of Adult Stroke Rehabilitation Care : A Clinical Practice Guideline. Stroke 2005, 36:e100-e143.
  32. Eack SM, Greenwald DP, Hogarty SS. Cognitive enhancement therapy for adults with autism spectrum disorder: results of an 18-month feasibility study. J Autism Dev Disord 2013; 43(12):2866-77.
  33. Eack SM, Hogarty GE, et al. Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia. Arch Gen Psychiatry. 2010;67(7):674-682.
  34. ECRI Institute Evidence Report. Cognitive Rehabilitation for the Treatment of Traumatic Brain Injury. October 2009, Issue Number 175. (Accessed 06/25/14).
  35. ECRI Institute. Health Technology Assessment. Cognitive Rehabilitation Therapy for Traumatic Brain Injury. (10/22/07) (Accessed March 31, 2008).
  36. Flanagan SR, Cantor JB, Ashman TA. Traumatic brain injury: future assessment tools and treatment prospects. Neuropsychiatr Dis Treat. 2008 Oct;4(5):877-92.
  37. Florida Medicare Part B Local Coverage Determination. L6196 THERSVCS Therapy and Rehabilitation Services, 01/16/07.
  38. Florida Medicare Part B Local Coverage Determination. LCD for Therapy and Rehabilitation Services (L29289) (02/02/09); last updated 01/07/14.
  39. Hayes, Inc. HAYES Medical Technology Directory. Cognitive Rehabilitation for Traumatic Brain Injury. Lansdale, PA: Hayes, Inc.; August 2004. Update performed 11/30/07.
  40. Huntley JD, Gould RL, Liu K, Smith M, Howard RJ. Do cognitive interventions improve general cognition in dementia? A meta-analysis and meta-regression. BMJ Open. 2015 Apr 2;5(4):e005247.
  41. Institute of Medicine of the National Academies. Report Brief: Cognitive Rehabilitation Therapy for Traumatic Brain Injury Evaluating the Evidence. Accessed at http://www.iom.edu/ on 06/17/13.
  42. Katz DI, Ashley MJ, O’Shanick GJ, Connors SH. Cognitive rehabilitation: the evidence, funding and case for advocacy in brain injury. McLean, VA: Brain Injury Association of America, 2006.
  43. Koorenhof L, Baxendale S, Smith N. Memory rehabilitation and brain training for surgical temporal lobe epilepsy patients: A preliminary report. Seizure 2012; 21(3):178-82.
  44. Kurz A, Thone-Otto A, Cramer B. CORDIAL: cognitive rehabilitation and cognitive-behavioral treatment for early dementia in Alzheimer disease: a multicenter, randomized, controlled trial. Alzheimer Dis Assoc Disord 2012; 26(3):246-53.
  45. Langenbahn DM, Ashman T, Cantor J. An evidence-based review of cognitive rehabilitation in medical conditions affecting cognitive function. Arch Phys Med Rehabil 2013; 94(2):271-86.
  46. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for attention deficits following stroke. The Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD002842. DOI: 10.1002/14651858.CD002842.
  47. Lobo MA, Galloway JC. Assessment and stability of early learning abilities in preterm and full-term infants across the first two years of life. Res Dev Disabil. 2013 May;34(5):1721-30.
  48. Majid MJ, Lincoln NB, Weyman N. Cognitive rehabilitation for memory deficits following stroke. The Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002293. DOI: 10.1002/14651858.CD002293.
  49. Malia K, Law P, Sidebottom L, Bewick K, Danziger S, Schold-Davis E, Martin-Scull R, Murphy K, Vaidya A. Recommendations for Best Practice in Cognitive Rehabilitation Therapy: Acquired Brain Injury. The Society for Cognitive Rehabilitation (2004). Accessed at www.cognitive-rehab.org.uk on 06/01/13.
  50. Miller EL, et. al. Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient : A Scientific Statement From the American Heart Association. Stroke. 2010;41:2402-2448.
  51. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke, The Cochrane Database of Systematic Reviews 2007, Issue 3m Art. No.: CD002293. DOI: 10.1002/14651858.CD002293.pub2.
  52. National Academy of Neuropsychology. Cognitive rehabilitation. Official Statement of the National Academy of Neuropsychology. NAN Position Papers. Denver, CO: NAN; May 2002. (Accessed 06/25/14).
  53. National Institute for Health and Care Excellence (NICE). Clinical Guideline: Stroke rehabilitation (CG162), June 2013.
  54. National Institutes of Health: National Institute of Neurological Disorders and Stroke. Stroke (March 29, 2012). Accessed at http://www.nlm.nih.gov/ on 05/31/13.
  55. Rabinowitz AR, Levin HS. Cognitive sequelae of traumatic brain injury. Psychiatr Clin North Am. 2014 Mar;37(1):1-11.
  56. Rajan J, Udupa S, Bharat S.. Hypoxia: Can Neuropsychological Rehabilitation Attenuate Neuropsychological Dysfunction. Indian J Psychol Med. 2010 Jan-Jun; 32(1): 65–68.
  57. Reichow B, Servili C, Yasamy MT. Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review. PLoS Med 2013; 10(12):e1001572.
  58. Ross KA, Dorris L, McMillan T. A systematic review of psychological interventions to alleviate cognitive and psychosocial problems in children with acquired brain injury. Dev Med Child Neurol. 2011 Aug;53(8):692-701.
  59. Salazar AM, Warden DL, Schwab K, Spector J, Braverman S, Walter J, Cole R, Rosner MM, Martin EM, Ecklund J, Ellenbogen RG. Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA. 2000 Jun 21; 283(23): 3075-81.
  60. Samėnienė J, Kriščiūnas A, Endzelytė E. The evaluation of the rehabilitation effects on cognitive dysfunction and changes in psychomotor reactions in stroke patients. Medicina (Kaunas) 2008; 44(11).
  61. The Brain Injury Association of America Position Paper. Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury. November 2006. Accessed at http://www.biausa.org on 06/25/14.
  62. The Society for Cognitive Rehabilitation. What is Cognitive Rehabilitation Therapy? © 2010-2012, The Society for Cognitive Rehabilitation.
  63. The Society for Cognitive Rehabilitation. Recommendations for Best Practice in Cognitive Rehabilitation Therapy: Acquired Brain Injury. © The Society for Cognitive Rehabilitation (2004). Accessed at http://www.societyforcognitiverehab.org on 06/25/14.
  64. Turner-Stokes L, Disler PB, Nair A, Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. The Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004170. DOI: 10.1002/14651858. CD004170.pub2.
  65. Wang M, Reid D. Using the virtual reality-cognitive rehabilitation approach to improve contextual processing in children with autism. ScientificWorldJournal 2013; 2013:716890.
  66. Wylie GR, Freeman K, Thomas A, Shpaner M, OKeefe M, Watts R, Naylor MR. Cognitive Improvement after Mild Traumatic Brain Injury Measured with Functional Neuroimaging during the Acute Period. PLoS One. 2015 May 11;10(5):e0126110.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/25/15.

GUIDELINE UPDATE INFORMATION:

04/25/02

Annual review of investigational status; no change.

05/15/03

Medical Coverage Guideline Reviewed; no change (investigational).

05/15/04

Review and revision of guideline consisting of updated references, no change to investigational status.

05/15/05

Review and revision of guideline consisting of updated references.

05/15/06

Review and revision of guideline consisting of updated references.

05/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

05/15/08

Scheduled review; no change in position statement. Update references.

06/15/09

Scheduled review; no change in position statement. Update references.

06/15/10

Biennial review; position statement revised to include indication for traumatic brain injury, and Medicare exception statement revised. Reference section updated.

09/15/10

Position Statement revised for clarification, and formatting changes.

09/15/11

Revision; formatting changes.

07/15/12

Scheduled review. Revised description and position statement. Updated references. Reformatted guideline.

01/01/13

Annual CPT coding update. Revised code descriptor for 97532.

07/15/13

Scheduled review. Revised description section, position statement and program exceptions section. Updated references and reformatted guideline.

08/15/14

Scheduled review. Revised position statement. Updated references and reformatted guideline.

07/15/15

Scheduled review. Position statement maintained. Updated references and reformatted guideline.

Date Printed: August 21, 2017: 07:48 PM