Reimbursement and Regulatory Policy Resources Medicare Part A

Reimbursement and

Regulatory Policy Resources

Medicare Part A Policy Update

The 2012 AOTA Annual Conference & Expo

Indianapolis, Indiana

SC 204

April 27, 2012 9:30-11:00 am

CC 105-106

Medicare Part A Policy Update

HANDOUT (2012)

TABLE OF CONTENTS

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Medicare Fact Sheets

• CMS Fact Sheet: Rehabilitation Therapy Information Resource for Medicare (May

2011)

• CMS Fact Sheet: Inpatient Rehabilitation Therapy Services: Complying with

Documentation Requirements (March 2011)

• CMS Fact Sheet: Medicare Fraud & Abuse: Prevention, Detection, and Reporting

(October 2011)

Policy and Reimbursement

• Medicare 101: Understanding the Basics (OT Practice, 2007)

• Medicare SNF Requirements (www.aota.org/News/AdvocacyNews/SNF-

Requirements.aspx)

• AOTA Analysis: Final Skilled Nursing Facility PPS Rule for FY 2012

• Advocating for Appropriate Occupational Therapy in SNFs (OT Practice, 2011)

• Joint Guidelines for Therapy Co-treatment under Medicare (2012)

• Medicare Part A Home Health Requirements

(www.aota.org/News/AdvocacyNews/Part-A-Home-Health.aspx)

• AOTA Analysis: Final Home Health PPS Rule for CY 2012

• CMS Clarifies Continuing Qualifying Service To Ensure Access to OT in Home

Health Rule (OT Practice, 2012)

• AOTA Home Health Documentation Guide (2011)

• AOTA Guidance for Completing Functional Reassessments and Documentation in

Medicare Home Health (April 2011)

• AOTA Fact Sheet: OT/OTA Student Supervision & Medicare Requirements (August

2011)

Coding

• Commonly Used CPT Codes for Occupational Therapy (2012)

• Selected HCPCS Level II Codes for Occupational Therapy (2012)

• Does Occupational Therapy Need Revised CPT Codes? (OT Practice, 2012)

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Medicare Fact Sheets

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services

Rehabilitation Therapy InformationResource for MedicareMedicare Part B provides coverage for many types of therapy services. This fact sheet is designed to provide education on rehabilitation therapy services, coverage requirements, payment systems, and points of contact for further information.

Medicare Therapy HighlightsAll Medicare therapy-related Change Requests (CRs) and Medicare Learning Network® (MLN) Matters® Articles can be found at http://www.cms.gov/Transmittals on the Centers for Medicare & Medicaid Services (CMS) website.

Recent therapy-related CRs include the following:•

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2011 Update to the Therapy Code List – Effective January 1, 2011 (CR 7364)

Reporting of Service Units With HCPCS – Effective March 21, 2011 (CR 7247)

Additions To and Revisions of Existing G-Codes for the Reporting of Skilled Nursing Services and Skilled Therapy Services in the Home Health or Hospice Setting – Effective January 1, 2011 (CR 7182)

Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services – Effective January 1, 2011 (CR 7050)

Clarifications and Updates of Therapy Services Policies – Effective July 11, 2010 (CR 6980)

Therapy Cap Values for Calendar Year (CY) 2010 – Effective January 1, 2010 (CR 6660)

DME MAC Instructions for Therapy Caps 2009 – Effective July 27, 2009 (CR 6497)

Speech-Language Pathology Private Practice Payment Policy – Effective July 6, 2009 (CR 6381)

New Non-physician Practitioner Specialty Code for Speech Language Pathologists – Effective July 6, 2009 (CR 6292)

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ICN 006773 May 2011

http://www.cms.gov/Transmittals

Recent therapy-related MLN Matters® Articles includethe following:

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Sections 3103 and 3104 of the Patient Protection and Affordable Care Act (PPACA) Extends Certain Payment Provisions Under the Medicare Program Related to Therapy Cap Exceptions and the Billing by Independent Laboratories for the Technical Component of Physician Pathology Services Furnished to Hospital Patients (SE0931) http://www.cms.gov/MLNMattersArticles/downloads/SE0931.pdf

Outpatient Therapy Cap Values for CY 2011 (MM7107) http://www.cms.gov/MLNMattersArticles/downloads/MM7107.pdf

Therapy Provider ContactsThe Medicare Contractor who pays Medicare Part B claims is the best source of answers to specific Medicare questions. Contractors are carriers, Fiscal Intermediaries (FIs), or Medicare Administrative Contractors (MACs), who provide customer service, develop local policies, and educate providers. If you have questions, please contact your Medicare Carrier, FI, or A/B MAC, at their toll-free number. For a list of the toll-free numbers, visit http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

If you have difficulty communicating with your contractor, refer to the Regional Office Overview web page at http://www.cms.gov/RegionalOffices to identify the CMS Regional Office that services your area of operations and contact them for assistance.

CMS Regulations & Program GuidanceExtension of Therapy Cap Exceptions

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008. This legislation extended the exceptions process to the therapy caps through December 31, 2009. The Temporary Extension Act of 2010, enacted on March 2, 2010, extended the therapy cap exceptions process through March 31, 2010. On March 23, 2010, the PPACA extended the exceptions process for outpatient therapy caps for services furnished on or after January 1, 2010, through December 31, 2010. On December 15, 2010, the Medicare and Medicaid Extenders Act of 2010 (MMEA) extended the exceptions process for services furnished on or after January 1, 2011, through December 31, 2011. Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate.The therapy caps are determined on a calendar year basis, so all patients begin a new cap year on January 1, 2011. For physical therapy and speech-language pathology services combined, the limit on incurred expenses was $1,860 in CY 2010 and is $1,870 in CY 2011. For occupational therapy services, the limit was $1,860 for CY 2010 and is $1,870 in CY 2011. These caps do not apply to services billed by hospitals.

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http://www.cms.gov/MLNMattersArticles/downloads/SE0931.pdf


http://www.cms.gov/MLNMattersArticles/downloads/MM7107.pdf

http://www.cms.gov/MLNMattersArticles/downloads/MM7107.pdf

http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip


http://www.cms.gov/RegionalOffices

For more policy information, visit:•

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Therapy Services – http://www.cms.gov/TherapyServices

“Medicare Benefit Policy Manual” (Chapter 15) – http://www.cms.gov/manuals/Downloads/bp102c15.pdf

“Medicare Claims Processing Manual” (Chapter 5) – http://www.cms.gov/manuals/downloads/clm104c05.pdf

Program Transmittals – http://www.cms.gov/Transmittals

Quarterly Provider Updates – http://www.cms.gov/QuarterlyProviderUpdates

Outpatient Therapy ServicesRefer to the 11 Part B Billing Scenarios for PTs and OTs at http://www.cms.gov/TherapyServices on the CMS website. These scenarios are designed to clarify existing therapy policy and to provide guidance on current Medicare Part B billing issues relevant to Physical Therapists (PTs) and Occupational Therapists (OTs), and to the services they provide. For more information, visit:

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Physician Fee Schedule (PFS) – http://www.cms.gov/PhysicianFeeSched/01_overview.asp

Physician Fee Schedule Search – http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

National Correct Coding Initiative Edits – http://www.cms.gov/NationalCorrectCodInitEd

Beneficiary Notices Initiative (BNI) – http://www.cms.gov/BNI/01_overview.asp

Provider EnrollmentVisit the Medicare Provider-Supplier Enrollment web page at http://www.cms.gov/MedicareProviderSupEnroll for Medicare enrollment information for institutional providers, physicians, practitioners, and suppliers of medical and health services. For more information, visit the following websites:

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Provider Enrollment Forms – http://www.cms.gov/CMSForms/CMSForms/list.asp

Provider-Supplier Enrollment Contacts – http://www.cms.gov/MedicareProviderSupEnroll

Medicare Payment SystemsFor specific payment system information, visit:

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Ambulatory Surgical Centers – http://www.cms.gov/center/asc.asp

Critical Access Hospitals – http://www.cms.gov/center/cah.asp

Durable Medical Equipment – http://www.cms.gov/center/dme.asp

Home Health Agency – http://www.cms.gov/center/hha.asp

Hospice – http://www.cms.gov/center/hospice.asp

Hospital – http://www.cms.gov/center/hospital.asp

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http://www.cms.gov/TherapyServices

http://www.cms.gov/manuals/Downloads/bp102c15.pdf

http://www.cms.gov/manuals/Downloads/bp102c15.pdf

http://www.cms.gov/manuals/downloads/clm104c05.pdf


http://www.cms.gov/Transmittals

http://www.cms.gov/QuarterlyProviderUpdates

http://www.cms.gov/QuarterlyProviderUpdates

http://www.cms.gov/TherapyServices

http://www.cms.gov/PhysicianFeeSched/01_overview.asp

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

http://www.cms.gov/NationalCorrectCodInitEd

http://www.cms.gov/BNI/01_overview.asp

http://www.cms.gov/MedicareProviderSupEnroll


http://www.cms.gov/CMSForms/CMSForms/list.asp


http://www.cms.gov/center/asc.asp

http://www.cms.gov/center/cah.asp

http://www.cms.gov/center/dme.asp

http://www.cms.gov/center/hha.asp

http://www.cms.gov/center/hospice.asp

http://www.cms.gov/center/hospital.asp

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Physician – http://www.cms.gov/center/physician.asp

Skilled Nursing Facility – http://www.cms.gov/center/snf.asp

Other Provider Types – http://www.cms.gov/center/provider.asp

Therapy-Related Outreach and EducationRefer to the learning resources and products listed below at http://www.cms.gov/MLNProducts on the CMS website.

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Medicare Fraud & Abuse Fact Sheet

Medicare Physician Guide

Medicare Secondary Payer Fact Sheet

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The Medicare Appeals Process: Five Levels to Protect Providers, Physicians, and Other Suppliers Brochure

Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT, and RAC Booklet

Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers

The Medicare Overpayment Collection Process Fact Sheet

Therapy Studies and Reports – Policy and UtilizationFor information related to therapy utilization and policy, including CMS Reports to Congress, CMS Contracted Reports, and Other Government Reports, visit http://www.cms.gov/TherapyServices/SAR/list.asp on the CMS website.

Therapy Professional Association ContactsTo contact one of the therapy professional associations, visit:

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American Occupational Therapy Association (AOTA) – http://www.aota.org

American Physical Therapy Association (APTA) – http://www.apta.org

American Speech-Language-Hearing Association (ASHA) – http://www.asha.org

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http://www.cms.gov/center/physician.asp

http://www.cms.gov/center/snf.asp

http://www.cms.gov/center/provider.asp

http://www.cms.gov/MLNProducts


http://www.cms.gov/TherapyServices/SAR/list.asp

http://www.cms.gov/TherapyServices/SAR/list.asp

http://www.aota.org

http://www.apta.org

http://www.asha.org

This fact sheet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For-Service Providers. For additional information, visit the MLN’s web page at http://www.cms.gov/MLNGenInfo on the CMS website.

Your feedback is important to us and we use your suggestions to help us improve our educational products, services and activities and to develop products, services and activities that better meet your educational needs. To evaluate Medicare Learning Network® (MLN) products, services and activities you have participated in, received, or downloaded, please go to http://www.cms.gov/MLNProducts and click on the link called ‘MLN Opinion Page’ in the left-hand menu and follow the instructions.

Please send your suggestions related to MLN product topics or formats to [email protected].

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http://www.cms.gov/MLNGenInfo


mailto:[email protected]

Official CMS Information forMedicare Fee-For-Service Providers


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Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

FACT SHEET

This fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to inpatient rehabilitation services and provides information on the documentation needed to support a claim submitted to Medicare for inpatient rehabilitation services.

The Centers for Medicare & Medicaid Services (CMS) developed the CERT Program to produce a national Medicare Fee-For-Service (FFS) error rate, as required by the Improper Payments Information Act. CERT randomly selects a small sample of Medicare FFS claims and reviews those claims and medical records from providers/suppliers who submitted them for compliance with Medicare coverage, coding, and billing rules.

In order to accurately measure the performance of the Medicare claims processing contractors and to gain insight into the causes of errors, CMS calculates both a national Medicare FFS paid claims error rate and a provider compliance error rate. The results of these reviews are published in an annual report and semi-annual updates.

CMS strives to eliminate improper payments in the Medicare Program to maintain the Medicare trust funds and protect patients.

Errors Identified Through the CERT Review ProcessCERT identified the following issues with inpatient rehabilitation services:

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Documentation does not support medical necessity;Missing, incomplete, or illegible signature; andCoding errors.

Inpatient Rehabilitation Facility (IRF) ServicesIRFs provide intensive rehabilitation services using an interdisciplinary team approach in a hospital environment. Admission to an IRF is appropriate for patients with complex nursing, medical management, and rehabilitative needs.

1ICN 905643 March 2011

Medical Necessity at the Time of AdmissionDeterminations of whether IRF stays are reasonable and necessary must be

based on an assessment of each patient’s individual care needs. In order for IRF care to be considered reasonable and necessary, the documentation in the patient’s

IRF medical record must demonstrate a reasonable expectation that the following criteria were met at the time of admission to the IRF. The patient must:

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Require active and ongoing intervention of multiple therapy disciplines (Physical Therapy [PT], Occupational Therapy [OT], Speech-Language Pathology [SLP], or prosthetics/orthotics), at least one of which must be PT or OT;

Require an intensive rehabilitation therapy program, generally consisting of: 3 hours of therapy per day at least 5 days per week; orIn certain well-documented cases, at least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period, beginning with the date of admission;

Reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program (the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement, expected to be made within a prescribed period of time and as a result of the intensive rehabilitation therapy program, that will be of practical value to improve the patient’s functional capacity or adaptation to impairments); Require physician supervision by a rehabilitation physician, with face-to-face visits at least 3 days per week to assess the patient both medically and functionally and to modify the course of treatment as needed; and Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care.

Intensive Level of Rehabilitation ServicesThe information in the patient’s IRF medical record must document a reasonable expectation that, at the time of admission to the IRF, the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs. Although the intensity of these services can be reflected in various ways, the generally-accepted standard by which the intensity of these services is typically demonstrated in IRFs is by the provision of intensive therapies at least 3 hours a day for 5 days a week. However, this is not a “rule of thumb,” and the intensity of therapy services provided in IRFs could also be demonstrated by the provision of 15 hours in a 7-consecutive day period starting from the date of admission, in certain well-documented cases. Therapy minutes cannot be rounded for the purposes of documenting the required intensity.

The patient’s IRF medical record must document that the required therapy treatments began within 36 hours from midnight of the day of admission to the IRF. Therapy evaluations done in the IRF constitute initiation of the required therapy services.

The standard of care for IRF patients is one-on-one therapy. The benefit to the patient of group therapy must be well-documented and group therapy may not be the preponderance of therapy provided to the patient. Time spent in family conferences does not count toward intensity of therapy requirements.

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NOTE: While patients requiring an IRF stay are expected to need and receive an intensive rehabilitation therapy program, this may not be true for a limited number of days during a patient’s IRF stay because the patient’s needs vary over time. If the specific reasons for a break in the provision of therapy services is appropriately documented in the patient’s IRF medical record, such a break in service (of limited duration) will not affect the determination of the medical necessity of the IRF admission. Medicare Contractors may approve these brief exceptions.

Interdisciplinary Team Approach to the Delivery of CareThe complexity of the patient’s condition must be such that the rehabilitation goals indicated in the preadmission screening, the post-admission physician evaluation, and the overall plan of care can only be achieved through periodic team conferences of an interdisciplinary team of medical professionals. The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals. Team conferences must be held once a week; a week is defined as 7 consecutive calendar days that begin the day of admission. A regularly-scheduled weekly team conference meets this requirement. At a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the IRF medical record):

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A rehabilitation physician with specialized training and experience in rehabilitation services;A registered nurse with specialized training or experience in rehabilitation;A social worker or a case manager (or both); andA licensed or certified therapist from each discipline involved in treating the patient.

The weekly interdisciplinary team meeting must be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient’s treatment in the IRF. The physician must document concurrence with all decisions made by the interdisciplinary team. Documentation must include the name and professional designation of each interdisciplinary team member in attendance.

The periodic interdisciplinary team conferences must focus on:

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Assessing the patient’s progress toward rehabilitation goals;Considering possible resolutions to any problems that could impede the patient’s progress toward the goals;Reassessing the validity of the rehabilitation goals previously established; andMonitoring and revising the treatment plan, as needed.

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Measurable ImprovementTo justify a continued IRF stay, the documentation in the patient’s medical record

must demonstrate an ongoing requirement for an intensive level of rehabilitation services and an interdisciplinary team approach to care. The IRF medical record

must demonstrate the patient is making functional improvements that are ongoing, sustainable, and of practical value, as measured against the patient’s condition at the start of treatment.

Documentation of IRF ServicesThe patient’s medical record at the IRF must contain the following documentation.

Required Preadmission ScreeningA preadmission screening is a detailed and comprehensive evaluation of the patient’s condition and need for rehabilitation therapy and medical treatment that must be conducted by a licensed or certified clinician(s) (appropriately trained to assess the patient medically and functionally) within the 48 hours immediately preceding the IRF admission. This screening is the initial determination of whether the patient meets the requirements for IRF admission.

If the preadmission screening is completed more than 48 hours prior to admission, there must be a reassessment. The reassessment can be completed by telephone. Any changes from the previous assessment must be documented.

While a physician extender can complete the preadmission screening, the rehabilitation physician must give concurrence that the patient meets the requirements for IRF admission. A rehabilitation physician must review, sign, and date the screening before the patient is admitted to the IRF. The preadmission screening can be completed in person or by telephone (a preadmission screening conducted entirely by telephone will not be accepted without transmission of the patient’s medical records from the referring hospital to the IRF and a review of those records by licensed or certified clinical staff in the IRF).

Preadmission screening documentation must justify that the patient requires, will benefit significantly from, and is able to actively participate in intensive rehabilitation therapy. Check-off lists are not acceptable documentation. The preadmission screening documentation must include:

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The specific reasons that led the IRF clinical staff to conclude the IRF admission would be reasonable and necessary;The patient’s prior level of function;The patient’s expected level of improvement;The expected length of time necessary to achieve the expected level of improvement;An evaluation of the patient’s risk for clinical complications;Treatments needed (OT, PT, SLP, or prosthetics/orthotics);The expected frequency and duration of treatment in the IRF;

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The anticipated discharge destination;Any anticipated post-discharge treatments; andOther information relevant to the care needs of the patient.

Required Post-Admission Physician EvaluationThe purpose of the post-admission physician evaluation is to document the patient’s status on admission to the IRF, compare it to that noted in the preadmission screening documentation, and begin development of the patient’s expected course of treatment that will be completed with input from all of the interdisciplinary team members in the overall plan of care. A dated, timed, and authenticated post-admission physician evaluation must be retained in the patient’s IRF medical record. The post-admission physician evaluation must:

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Be performed by a rehabilitation physician and completed within the first 24 hours after admission to the IRF;Support medical necessity of admission; Identify any relevant changes that may have occurred since the preadmission screening; andInclude a documented History and Physical (H&P) exam, as well as a review of prior and current medical and functional conditions and comorbidities.

A resident or physician extender (as defined in Section 1861(s)(2)(K) of the Social Security Act [SSA]) can complete the H&P component of the evaluation.If a resident or physician extender completes the H&P, the rehabilitation physician must still visit the patient and complete the other required parts.

If the post-admission physician evaluation does not support the continued appropriateness of the IRF services for the patient, the IRF shall begin the discharge process immediately. Services after the 3rd day will not be considered reasonable and necessary, and the IRF will be paid at the appropriate payment rate for IRF patient stays of 3 days or less.

Required Individualized Overall Plan of CareThe individualized overall plan of care is synthesized by the rehabilitation physician from the preadmission screening, post-admission physician evaluation, and information garnered from the assessments of all disciplines involved in treating the patient. The individualized overall plan of care must:

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Be completed within the first 4 days of the IRF admission (may be completed at the same time as the post-admission physician evaluation, as long as all required elements are included);Support medical necessity of admission;Detail the patient’s medical prognosis and anticipated interventions (PT, OT, SLP, and prosthetic/orthotic therapies) required during the IRF stay, including:

Expected intensity (number of hours per day),Expected frequency (number of days per week), andExpected duration (number of total days during IRF stay);

Detail functional outcomes; andDetail discharge destination from the IRF stay.

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Detailed expectations for the course of treatment must be based on consideration of the patient’s

impairments, functional status, complicating conditions, and any other contributing factors.

Required Admission OrdersAdmission orders must be generated by a physician at the time of admission. Any licensed physician may generate the admission order. Physician extenders, working in collaboration with the physician, may also generate the admission order. These admission orders must be retained in the patient’s IRF medical record.

Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)The IRF-PAI is used to gather data to determine the payment for each Medicare Part A FFS patient admitted to an IRF. The IRF-PAI form must be included in the patient’s IRF medical record in either electronic or paper format.

Information in the IRF-PAI must correspond with all information in the patient’s IRF medical record. The IRF-PAI must be dated, timed, and authenticated in the written or electronic form. One signature (attached in some way to the IRF-PAI, either in a cover page or handwritten somewhere on the form) from the person who completed (or transmitted) the IRF-PAI will be sufficient.

Avoid CERT ErrorsIn order to avoid a CERT error, check your medical record documentation and claims submission practices to ensure the following:

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The physician must sign and date the preadmission screening before the patient is admitted to the IRF. Therapy provided in the IRF should be provided primarily one-on-one with a therapist. Group treatment may be used as an adjunct to the individual treatment when it is well-documented in the patient’s medical record that this better meets the patient’s needs. Submit claims in accordance with CMS billing instructions for IRFs. For more information, refer to Internet-Only Manual (IOM) Publication (Pub.) 100-04, “Medicare Claims Processing Manual,” Chapter 3, Section 140 at http://www.cms.gov/manuals/downloads/clm104c03.pdf on the CMS website. Report the correct patient discharge status code. To obtain a list of all available patient discharge status codes for Medicare claims, refer to the Special Edition Medicare Learning Network’s® MLN Matters® Article SE0801, “Clarification of Patient Discharge Status Codes and Hospital Transfer Policies” at http://www.cms.gov/MLNMattersArticles/downloads/SE0801.pdf on the CMS website. Submit the IRF-PAI data collected on a Medicare Part A FFS or Medicare Part C (Medicare Advantage) inpatient to the CMS National Assessment Collection Database by the 17th calendar day from the date of the inpatient’s discharge. For more information on the IRF-PAI, visit http://www.cms.gov/InpatientRehabFacPPS/04_IRFPAI.asp on the CMS website.

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http://www.cms.gov/InpatientRehabFacPPS/04_IRFPAI.asp

http://www.cms.gov/InpatientRehabFacPPS/04_IRFPAI.asp

ResourcesCMS guidance regarding IRF coverage and documentation requirements is

available through the following resources:

For more information on Medicare’s inpatient rehabilitative therapy services requirements, refer to CMS IOM, Pub. 100-02, “Medicare Benefit Policy Manual,” Chapter 1, Section 110 at http://www.cms.gov/Manuals/Downloads/bp102c01.pdf on theCMS website.

For more information on IRF coverage requirements, visit http://www.cms.gov/InpatientRehabFacPPS/04_Coverage.asp on the CMS website.

For more IRF updates, refer to the most recent Fiscal Year (FY) Final Rule for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) at http://www.cms.gov/InpatientRehabFacPPS/LIRFF/list.asp or to the CMS IRF Spotlight web page at http://www.cms.gov/InpatientRehabFacPPS/02_Spotlight.asp on the CMS website.






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http://www.cms.gov/Manuals/Downloads/bp102c01.pdf

http://www.cms.gov/InpatientRehabFacPPS/04_Coverage.asp

http://www.cms.gov/InpatientRehabFacPPS/04_Coverage.asp

http://www.cms.gov/InpatientRehabFacPPS/LIRFF/list.asp

http://www.cms.gov/InpatientRehabFacPPS/LIRFF/list.asp

http://www.cms.gov/InpatientRehabFacPPS/02_Spotlight.asp

http://www.cms.gov/InpatientRehabFacPPS/02_Spotlight.asp





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Medicare Fraud & Abuse: Prevention, Detection, and Reporting

FACT SHEET

Medicare fraud and abuse is a serious problem requiring your attention. Although there is no precise measure of health care fraud and the majority of health care providers are honest and well-intentioned, a minority of providers who are intent on abusing the system can cost taxpayers billions of dollars and put beneficiaries’ health and welfare at risk. The impact of these losses and risks is magnified by the growing number of people served by Medicare and the increased strain on Federal and state budgets.

You play a vital role in protecting the integrity of the Medicare Program. To combat fraud and abuse, you need to know what to watch for to protect your organization from potential abusive practices, civil liability, and perhaps criminal activity. This fact sheet gives you some of the tools you need to protect the Medicare Program, including the definitions of Medicare fraud and abuse, laws used to address fraud and abuse, overviews of partnerships among government agencies engaged in fighting fraud and abuse, and resources on how you can report suspected fraud and abuse.

What Is Medicare Fraud?In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts.

Fraud schemes range from solo to broad-based operations by an institution or group. Anyone can commit health care fraud. You may even know someone who has committed fraud. Organized crime also is infiltrating the Medicare Program and masquerading as Medicare providers and suppliers. Examples of Medicare fraud may include:

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Knowingly billing for services that were not furnished and/or supplies not provided, including billing Medicare for appointments that the patient failed to keep; andKnowingly altering claims forms and/or receipts to receive a higher payment amount.

To learn about real-life cases of Medicare fraud and abuse and the consequences for culprits, visit http://www.stopmedicarefraud.gov/HEATnews on the Internet.

ICN 006827 October 20111

http://www.stopmedicarefraud.gov/HEATnews

http://www.stopmedicarefraud.gov/HEATnews

It is a crime to defraud the Federal Government and its programs. Punishment may involve imprisonment, significant fines, or both. Criminal penalties for health care fraud reflect the

serious harms associated with health care fraud and the need for aggressive and appropriate fraud prevention. In some states, providers and health care organizations may lose their licenses. Convictions also may result in exclusion from Medicare participation for a specified length of time. Medicare fraud may also result in civil liability.

What Is Medicare Abuse?Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced.

Examples of Medicare abuse may include:

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Misusing codes on a claim,Charging excessively for services or supplies, andBilling for services that were not medically necessary.

Both fraud and abuse can expose providers to criminal and civil liability.

Medicare Fraud and Abuse LawsThe False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), Social Security Act, and the U.S. Criminal Code are used to address fraud and abuse. Violations of these laws may result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from the Medicare Program, and criminal and civil liability.

NOTE: The fraudulent conduct addressed by these laws is also prohibited in Medicare Part C and Part D and in Medicaid, including fraud and abuse related to “dual eligibles.” “Dual eligibles” refers to individuals who are entitled to or enrolled in Medicare Part A or enrolled in Part B, and who are eligible for Medicaid.

False Claims Act (FCA)The FCA (31 United States Code [U.S.C.] Sections 3729-3733) protects the Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the Federal Government. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. An example may be a physician who submits claims to Medicare for medical services he or she knows were not provided. Civil penalties for violating the FCA may include fines and up to 3 times the amount of damages sustained by the Government as a result of the false claims. There also is a criminal FCA (18 U.S.C. Section 287). Criminal penalties for submitting false claims may include fines, imprisonment, or both. For more information on fraud, visit http://oig.hhs.gov/fraud on the Internet.

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Anti-Kickback StatuteThe Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)) makes it a criminal offense to knowingly

and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where remuneration is paid, received, offered, or solicited purposefully to induce or reward referrals of items or services payable by a Federal health care program, the Anti-Kickback Statute is violated. If an arrangement satisfies certain regulatory safe harbors, it is not treated as an offense under the statute. The safe harbor regulations are set forth at 42 Code of Federal Regulations (CFR) Section 1001.952. Criminal penalties for violating the Anti-Kickback Statute may include fines, imprisonment, or both. For more information, visit http://oig.hhs.gov/compliance/safe-harbor-regulations on the Internet.

Physician Self-Referral Law (Stark Law)The Physician Self-Referral Law (Stark Law) (42 U.S.C. Section 1395nn) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Penalties for physicians who violate the Physician Self-Referral Law (Stark Law) include fines as well as exclusion from participation in all Federal health care programs. For more information, visit http://www.cms.gov/PhysicianSelfReferralon the Centers for Medicare & Medicaid Services (CMS) website.

Criminal Health Care Fraud StatuteThe Criminal Health Care Fraud Statute (18 U.S.C. Section 1347) prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice:

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To defraud any health care benefit program; orTo obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program;

in connection with the delivery of or payment for health care benefits, items, or services. Proof of actual knowledge or specific intent to violate the law is not required. Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both.

ExclusionsUnder 42 U.S.C. Section 1320a-7, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) is required to impose exclusions from participation in all Federal health care programs on health care providers and suppliers who have been convicted of:

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Medicare fraud;Patient abuse or neglect;Felony convictions for other health care related fraud, theft, or other financial misconduct; orFelony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

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http://oig.hhs.gov/compliance/safe-harbor-regulations

http://oig.hhs.gov/compliance/safe-harbor-regulations

http://www.cms.gov/PhysicianSelfReferral

Exclusion means that, for a designated period, Medicare, Medicaid, and other Federal health care programs will not pay the provider for services performed or for services ordered by the

excluded party. Note that the OIG has discretion to impose permissive exclusions on a number of other grounds.

Civil Monetary Penalties (CMPs)Under 42 U.S.C. Section 1320a-7a, CMPs may be imposed for a variety of conduct, and different amounts of penalties and assessments may be authorized based on the type of violation at issue. Penalties range from up to $10,000 to $50,000 per violation. CMPs can also include an assessment of up to 3 times the amount claimed for each item or service, or up to 3 times the amount of remuneration offered, paid, solicited, or received. Examples of CMP violations include:

Presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false and fraudulent,Presenting a claim that the person knows or should know is for an item or service for which payment may not be made, andViolating the Anti-Kickback Statute.

Medicare Fraud and Abuse PartnershipsGovernment agencies partner to fight fraud and abuse, uphold the Medicare Program’s integrity, save and recoup taxpayer funds, and maintain health care costs and quality of care.

Centers for Medicare & Medicaid Services (CMS)CMS is a Federal agency within HHS that administers and oversees the Medicare and Medicaid Programs. CMS partners with the following entities and law enforcement agencies, among others, to prevent and detect fraud and abuse:

Program Safeguard Contractors (PSCs)/Zone Program Integrity Contractors (ZPICs);Medicare Drug Integrity Contractors (MEDICs);State and Federal law enforcement agencies, such as the OIG, Federal Bureau of Investigation (FBI), Department of Justice (DOJ), and State Medicaid Fraud Control Units (MFCUs);Medicare beneficiaries and caregivers;Senior Medicare Patrol (SMP) program;Physicians, suppliers, and other providers;Medicare Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (MACs) who pay claims and enroll providers and suppliers;Accreditation Organizations (AOs);Recovery Audit Program Recovery Auditors; andComprehensive Error Rate Testing (CERT) Contractors.

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Center for Program Integrity (CPI)CPI promotes the integrity of Medicare through audits and policy reviews, identification and

monitoring of program vulnerabilities, and support and assistance to states. CPI oversees those CMS interactions and collaborations with key stakeholders that relate to program integrity for the purposes of detecting, deterring, monitoring, and combating fraud and abuse.

Office of Inspector General (OIG)The OIG protects the integrity of the HHS’ programs, including Medicare, and the health and welfare of its beneficiaries. The OIG carries out its duties through a nationwide network of audits, investigations, inspections, and other related functions. The Inspector General has the authority to exclude individuals and entities who have engaged in fraud or abuse from participation in Medicare, Medicaid, and other Federal health care programs, and to impose CMPs for certain misconduct related to Federal health care programs. The OIG maintains a list of excluded parties called the List of Excluded Individuals/Entities (LEIE). For more information, visit http://oig.hhs.gov/exclusions on the Internet.

Health Care Fraud Prevention and Enforcement Action Team (HEAT)The DOJ and HHS established HEAT to build and strengthen existing programs to combat Medicare fraud while investing new resources and technology to prevent fraud and abuse. HEAT efforts have included expansion of the DOJ-HHS Medicare Fraud Strike Force that has been successful in fighting fraud. HEAT created the Stop Medicare Fraud website, which provides information about how to identify and protect against Medicare fraud and how to report it. For more information, visit http://www.stopmedicarefraud.gov on the Internet.

General Services Administration (GSA)The GSA maintains the Excluded Parties List System (EPLS) that includes information on entities debarred, suspended, proposed for debarment, excluded, or disqualified throughout the U.S. Government from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and non-financial assistance and benefits. For more information, visit https://www.epls.govon the Internet.

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http://www.stopmedicarefraud.gov

http://www.stopmedicarefraud.gov

https://www.epls.gov

Report Suspected FraudWhere Should I Report Fraud and Abuse?

I am a ... Report to ...Medicare Beneficiary For any complaints:

CMS Hotline: 1-800-MEDICARE (1-800-633-4227) orTTY 1-800-486-2048ORFor Medicare Managed Care or Prescription Drugs:1-877-7SafeRx (1-877-772-3379)

Medicare Provider OIG HotlinePhone: 1-800-HHS-TIPS (1-800-447-8477)Fax: 1-800-223-8164E-mail: [email protected]: 1-800-377-4950http://oig.hhs.gov/fraud/report-fraud/report-fraud-form.asp

Mail: Office of Inspector General Department of Health and Human Services Attn: Hotline P.O. Box 23489 Washington, DC 20026OR your local Medicare Carrier, FI, or MAC

Medicaid Beneficiary or Provider

OIG Hotline1-800-HHS-TIPS (1-800-447-8477)Fax: 1-800-223-8164E-mail: [email protected]: 1-800-377-4950http://oig.hhs.gov/fraud/report-fraud/report-fraud-form.asp

Mail: Office of Inspector General Department of Health and Human Services Attn: Hotline P.O. Box 23489 Washington, DC 20026OR your Medicaid State Agency (State Agency Fraud Units are listed at http://www.cms.gov/FraudAbuseforConsumers)

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If you prefer, you may provide your complaint anonymously to the OIG Hotline. No information will be entered in OIG record systems that could trace the complaint to you. In many cases,

however, the lack of contact information for the source prevents a comprehensive review of the complaint. The OIG encourages you to provide information on how to contact you for additional information.

Medicare and Medicaid beneficiaries can learn more about protecting themselves and spotting fraud by contacting their local SMP program. For more information about SMP or to find the local SMP, visit the SMP Locator at http://www.smpresource.org on the Internet.

For questions about billing procedures, billing errors, or questionable billing practices, contact your Medicare Carrier, FI, or MAC. For Medicare Carrier, FI, or MAC contact information, including toll-free telephone numbers, visit http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

ResourcesThe OIG and CMS offer a wealth of information regarding prevention, detection, and reporting of Medicare fraud and abuse.

For more information about the OIG and fraud, visit http://oig.hhs.gov/fraud on the Internet.

For more information about OIG e-mail updates, visit http://www.oig.hhs.gov/contact-us on the Internet.

For more information about CMS, visit http://www.cms.gov on the CMS website.

For the CMS Fraud Prevention Toolkit, which contains information for providers and information providers can give to beneficiaries, visit http://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp on the CMS website.

For more information about HEAT, visit http://www.stopmedicarefraud.gov/heattaskforce onthe Internet.

For more information about CMS Electronic Mailing Lists, visit http://www.cms.gov/MLNProducts/downloads/MailingLists_FactSheet.pdf on the CMS website.

For provider compliance educational materials, visit http://www.cms.gov/MLNProducts/45_ProviderCompliance.asp on the CMS website.

For more information about OIG Advisory Opinions, visit http://www.oig.hhs.gov/compliance/advisory-opinions on the Internet.

For more information about CMS Advisory Opinions, v is i t http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp on the CMS website.

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http://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp

http://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp

http://www.cms.gov/MLNProducts/downloads/MailingLists_FactSheet.pdf

http://www.cms.gov/MLNProducts/downloads/MailingLists_FactSheet.pdf

http://www.cms.gov/MLNProducts/45_ProviderCompliance.asp

http://www.cms.gov/MLNProducts/45_ProviderCompliance.asp

http://www.oig.hhs.gov/compliance/advisory-opinions

http://www.oig.hhs.gov/compliance/advisory-opinions

http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp

http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp


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________________________

Policy and Reimbursement

________________________

MONICA ROBINSON, MS, OTR/LOccupational Therapy Rehabilitation Systems Consultant, HCR

Manor Care, Toledo, OhioMember of the AOTA Alternatives to the Cap Committee and

AOTA’s CPT Coding Committee AOTA Administration & Management Special Interest Section

Communication/Reimbursement Liaison.

ABSTRACTMedicare is the largest health care payer in the United States,covering more than 42 million people. A high percentage ofoccupational therapy practitioners provide services to Medicarebeneficiaries. The Medicare benefit is available through sev-eral programs, each of which adheres to a different set ofrules and payment policies. Occupational therapy servicesare covered in these programs at various settings under spe-cific criteria. Occupational therapy practitioners must under-stand these rules and regulations in order to fully servicetheir patients and promote their profession. Congress regu-lates Medicare, and when we understand the rules and regu-lations, we can better advocate for occupational therapyservices or influence changes in the system.

LEARNING OBJECTIVESAfter reading this article, you should be able to: 1. Differentiate between the various Medicare programs.2. Identify basic Medicare Part B billing requirements.3. Identify the different Medicare contractors that administer

and manage the Medicare claims process.4. Identify general Medicare documentation requirements.

INTRODUCTIONAs the largest health care payer in the United States,Medicare covered more than 42 million people in 2005.Approximately 35.4 million of those covered are 65 years ofage or older, with the remaining 6.6 million under 65 with apermanent disability (Kaiser Family Foundation, 2005). Ahigh percentage of occupational therapy clients have medicalcoverage through the Medicare program.

Funding Medicare is an ongoing federal issue. Medicarewas 13% of the federal budget in 2005, costing a staggering$325 billion. Hospital inpatients made up 37% of those costs,followed by physicians and other providers, including outpa-tient therapy services (25%), skilled nursing facilities (5%),and home health (4%) (Kaiser Family Foundation, 2005).These escalating costs often result in Congress writing suchlegislation as the Balanced Budget Refinement Act of 1999

(Public Law 106-113) or the Medicare Modernization Act of2003 (Public Law 108-173) to help manage Medicare costs.Medicare legislation significantly affects our practice settingsand service delivery. Occupational therapy practitioners pro-vide services in most of the Medicare-approved settings.Certainly some clinicians work in settings that do not useMedicare funding; however, it is important to know andunderstand Medicare guidelines because many other insur-ance companies follow Medicare rules and apply the samecoverage decisions when approving health care services. Wemust understand the Medicare system and related legislationso that we can optimize our opportunities to practice andensure reimbursement for our practice, promote occupa-tional therapy services, and serve our clients fully.

HISTORY OF MEDICAREIn 1965, Congress established two programs to cover themedical costs for elderly people and persons with disabilities.These programs, commonly referred to as Medicare, wereincluded in Title XVIII of the Social Security Act Amend-ments of 1965 (Public Law 89-97). The “Hospital InsuranceBenefits for the Aged and Disabled,” also known as MedicarePart A, was created to provide partial funding for inpatienthospitalization and other institutional care. The second pro-gram, “Supplementary Medical Insurance Benefits for theAged and Disabled,” also known as Medicare Part B, was created to provide additional financial support for noninstitu-tional costs, such as physician and other health care providerservices. The Medicare Part B benefit was created as a volun-tary program that required additional monthly premiums tobe paid by the recipient.

Medicare established a third, managed care programoption under the Balanced Budget Act of 1997 (Public Law105-33) called “Medicare+Choice,” now referred to as“Medicare Advantage” or Medicare Part C. This program isoptional for Medicare recipients if they choose not to use thetraditional Medicare fee-for-service model (CCH EditorialStaff Productions, 2006).

The final Medicare option is the newly developedMedicare Part D, the “Voluntary Prescription Drug BenefitProgram.” The prescription drug program became availableto Medicare recipients in January 2006 (CCH Editorial StaffProductions, 2006).

To be eligible for any of the Medicare programs, one mustbe 65 years of age or older and eligible for Social Securitybenefits, survivor benefits, or railroad retirement benefits.People under 65 are eligible for Medicare if they are entitled

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AOTA Continuing Education ArticleEarn .1 AOTA CEU (one NBCOT PDU /one contact hour, see page CE-7 for details)

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to Social Security or railroad disability benefits or if theyhave end-stage renal disease or amyotrophic lateral sclerosisbenefits. Those who do not meet any of the aforementionedcategories and are 65 years of age or older can opt into theMedicare program by paying a monthly premium for Part A(CCH Editorial Staff Productions, 2006).

TYPES OF MEDICARE BENEFITSMedicare Part AThe Medicare Part A benefit includes inpatient hospitaliza-tion, inpatient rehabilitation, inpatient psychiatric care, long-term-care hospitals (LTCHs), skilled nursing facilities(SNFs), home health care, and hospice. Medicare Part A is paid in these settings under a specific set of rules. Reim-bursement is based on a prospective payment system (PPS),which is a comprehensive payment system that has an estab-lished rate for an episode of care based on initial diagnosesand presenting problems. A standardized set of criteria orassessments is used to determine the patient-related prob-lems and to translate the results into a payment rate. Reim-bursement fees and rates are established by Congress andmay vary or be adjusted annually.

It is important for practitioners to understand how theirservices are paid, so they can be knowledgeable care providers.In the PPS, occupational therapy practitioners should under-stand the balance between patient care and the costs associatedwith service delivery. For example, most supplies (reachers,dressing sticks, theraputty, splints) are bundled in the PPSrate. If we understand the financial implication of our serv-ices, we can advocate for our clients from a position ofknowledge and appreciation of the payment system. The following sections review the different Medicare Part A settings where occupational therapy practitioners work.

Inpatient Hospitals In 1983, the Medicare payment system dramatically changed.President Reagan signed into law the Medicare ProspectivePayment System as defined in the Social Security ActAmendments of 1983 (Public Law 98-21). Before this law,hospital services were paid by the costs, or fee for services.The new law established a per-case per diem rate based ondiagnostic categories called diagnosis-related groups (DRGs).The DRG bundled rate includes room and board; nursingservices; medication and supplies; diagnostic services; andother services, including occupational therapy. This flat ratealso includes supplies that occupational therapy practitionersmay issue to patients, such as activities of daily living (ADL)or exercise supplies.

The Medicare Part A benefit allows for 90 days of hospitalization per “spell of illness.” The beneficiary pays a deductible for the first 60 days of inpatient per spell of illness, and a copayment is required for Days 61 to 90.Additionally, each beneficiary has 60 days “hospital lifetimereserve days,” which can be at any time. When a beneficiary

chooses to use these days, there is a per-day copayment fee(CCH Editorial Staff Productions, 2006).

Inpatient Rehabilitation FacilitiesInpatient rehabilitation facilities (IRFs) provide intensiverehabilitation. Generally, patients receive 3 hours of com-bined therapy services (occupational therapy, physical ther-apy, speech-language pathology) a day plus other inpatientservices. Beginning in January 2002, IRFs were required tofollow a PPS. This program uses a per-discharge systembased on case mix groups (CMGs), which are functional-related groups. A modified version of the FIM™ is used toassess the patient and assign the CMG. The InpatientRehabilitation Facility Patient Assessment Instrument (IRF-PAI) is used to determine the category. The instrumentgathers information in nine key areas, including patient iden-tification; demographics; medical information; patient safety;and patient functional abilities, including cognition. The IRF-PAI is completed twice during the patient’s stay, once onadmission and again at discharge. These two combinedassessments establish the payment (CCH Editorial StaffProductions, 2006).

IRFs also are faced with adhering to the “75% rule.” This rule requires that 75% of the patients in a cost-reportingyear meet certain treatment categories (Medicare Program:Changes to the Medicare Claims Appeal Procedures, 2005).Some of these patients include those with stroke, spinal cordinjury, amputations, multiple trauma, brain injury, and twomajor joints with severe osteoarthritis. Facilities had a 3-yearphase-in period in which to comply with this regulation. Fullimplementation is expected for July 2007.

Inpatient Psychiatric FacilitiesThe Balanced Budget Refinement Act of 1999 created a newper diem PPS for inpatient psychiatric facilities. This systemuses a standard base rate that is adjusted by various factors.This PPS uses the International Classification of Diseases,Ninth Revision, Clinical Modification (ICD-9-CM) diagnosiscodes (Centers for Disease Control and Prevention & NationalCenter for Health Statistics, 2006) (not Diagnostic andStatistical Manual of Mental Disorders, 4th ed. [AmericanPsychiatric Association, 1994]) to establish the patient’sDRG. Adjustments to the payment rate are made based onage and for patients who have 1 or more of 17 comorbiditiesin addition to the diagnosed psychiatric condition. Paymentsalso are adjusted based on length of stay. The highest dayrate is the first day because of the number of assessmentsgiven. Payments from Days 2 through 21 are reduced, andfurther reductions are made from Day 22 onward (CCHEditorial Staff Productions, 2006).

Long-Term-Care HospitalsLTCHs treat patients who are very clinically complex andneed 25 or more days of skilled service. These patients have

very acute or chronic conditions that require extended serv-ices, including rehabilitation, respiratory therapy, pain man-agement, traumatic brain injury treatment, and close medicalmanagement. Payment is based on a DRG system on a per-discharge basis. The LTCH PPS also considers patient demo-graphics, discharge status, principal diagnosis, and anadditional eight diagnoses and six medical procedures inorder to determine the rate. These all contribute to classify-ing the patient in 1 of more than 500 LTCH DRGs (CCHEditorial Staff Productions, 2006).

Skilled Nursing FacilitiesMedicare defines specific criteria that a beneficiary must sat-isfy to receive the Medicare Part A benefit in an SNF. Thebeneficiary must (a) be referred by a physician, (b) have a 3-day qualifying stay in a hospital, (c) be admitted to the SNFwithin 30 days of the qualifying stay, and (d) require dailynursing or rehabilitation services at least 5 days a week. TheMedicare Part A SNF benefit allows for 100 skilled days ofservice per spell of illness. The first 20 days of care do notcost the beneficiary. Days 21 through 100 require a benefici-ary copayment. Any days beyond 100 are covered underMedicare Part B.

This PPS was introduced into the skilled nursing setting in 1998. Payment is based on a case mix–adjusted paymentsystem. The Minimum Data Set (MDS 2.0) is used to screenmultiple aspects of data on the patient (e.g., diagnosis, timespent in therapy, functional status, complicating medical fac-tors, medication). All these elements contribute to the overallpayment category. The payment categories are calledResource Utilization Groups (RUGs). The RUGs system has53 payment categories, and rehabilitation is defined in thehighest paying RUGs levels. This payment is based on thetime spent in therapy services and the number of disciplinesdelivering services. The MDS 2.0 is completed at specificintervals during the patient’s stay in order to adjust the RUGslevel and payment rate as appropriate.

Home Health CareTo qualify for the Medicare Part A home health benefit, thepatient must be homebound; be under the care of a physi-cian; and need skilled nursing or therapy services, whichmust be certified by a physician. The plan of care is reviewedand recertified every 60 days. The Medicare Part A homehealth benefit covers up to 100 visits per “spell of illness.”

For occupational therapy to be involved, a nurse, physicaltherapist, or speech-language pathologist must open thecase. After the case is opened, occupational therapy can be astand-alone skilled service and recertify the patient. Thehome health PPS began in October 2000. This PPS uses theOutcomes and Assessment Information Set (OASIS) to calcu-late payment rates. The OASIS gathers data on the patient’sdischarge needs; ADL; living arrangements; support systems;equipment management; medications; diagnosed conditions;

psychosocial status; and physical status, including sensory,skin, and neurological. Based on the data submitted from theOASIS, grouper software determines the appropriate HomeHealth Resources Group for payment. The OASIS is com-pleted at specific Medicare-defined intervals to establish thepayment rate. The Medicare Part A benefit does not have adeductible or copayment (Centers for Medicare & MedicaidServices [CMS], 2006b).

Hospice CareMedicare Part A hospice care is a unique program intendedfor beneficiaries whose physicians have certified that theyhave a terminal condition with a life expectancy of 6 monthsor less. When a patient opts into the hospice program, he orshe is agreeing to palliative care. Unlike many of the otherMedicare Part A services, hospice care does not limit thenumber of days of the benefit. At any time a patient canchoose to stop the hospice benefit and return to traditionalMedicare. Hospice care offers numerous benefits to thepatient and caregivers, including counseling, social services,pain control, home health aide services, homemaker services,medical supplies, inpatient respite care, and therapy services.Occupational therapy services are limited and generallyrelated to comfort, safety, quality of life issues, and caregivereducation and training.

Hospice services are based on a cost-related prospectivepayment. Payment rates are based on four categories: rou-tine home care, continuous home care, inpatient respite, andgeneral inpatient care.

Medicare Part BMedicare Part B is the supplementary medical insurance pro-gram. This voluntary program usually requires the benefici-ary to pay monthly premiums and a 20% copayment basedon the Medicare physician fee schedule (MPFS). MedicarePart B covers outpatient occupational therapy, physical ther-apy, and speech-language pathology; physician visits; durablemedical equipment (e.g., wheelchairs), prosthetics, orthotics,and supplies (DMEPOS); outpatient hospital services; outpa-tient mental health services; and clinical laboratory (e.g.,blood tests) and diagnostic tests. Payments for occupationaltherapy services are based on the MPFS. The MPFSs andcoding are discussed later in more detail.

Outpatient occupational therapy services are provided invarious settings (CMS, 2006d), including:n Private practice: Occupational therapist private practition-

ers (OTPPs) are required to have a National ProviderIdentifier number to bill for services

n Clinic, rehabilitation, or public health agenciesn Hospital outpatient clinics n SNFs: Services are provided for beneficiaries who have

exhausted the Medicare Part A benefit or are residents ofthe facility who did not have a 3-day qualifying hospital stay.

n Physician office: Therapy incident to physician services or

Earn .1 AOTA CEU (one NBCOT PDU /one contact hour, see page CE-7 for details)




as OTPPs in physician groups.n Home health care: This includes visits over the 100-day

Part A limit or when the patient does not meet the homehealth Part A benefit criterion.

n Comprehensive outpatient rehabilitation facilities (CORFs):CORFs provide a wide range of comprehensive and coordi-nated rehabilitation services. At a minimum, these includephysician, therapy , and psychosocial services.

Medicare Part CThe Medicare Advantage Plan (also referred to as MedicarePart C) replaced the Medicare+Choice program in 2006.Medicare assigns contracts to private insurance companies tomanage the beneficiary’s Medicare benefits. These plansinclude both Medicare Part A and Medicare Part B servicesand many include a prescription medication benefit. Often,the copayment for services under a Medicare Part C plan arelower for the beneficiary. However, these insurance compa-nies also are gatekeepers of service delivery and may requireprior approval before services are rendered, limit the benefi-ciary to a specific network of providers, or both.

The new Medicare Advantage Plan includes the followingoptions: Medicare preferred provider organizations, Medicarehealth maintenance organizations, Medicare private fee-for-service, Medicare Special Needs Plan, and Medicare medicalsavings account (CCH Editorial Staff Productions, 2006).Occupational therapy practitioners must effectively communi-cate with these plan providers. We need to identify the skilledservices we provide and how these services will benefit thepatient. Resources such as the Medicare National CoverageDeterminations (i.e., the procedures and services Medicarewill cover) (CMS, 2006e), The American Occupational TherapyAssociation’s (AOTA’s) Scope of Practice (2004), and the evi-dence-based practice resources on the AOTA Web site(www.aota.org) can be used to explain occupational therapyand the effectiveness of the services we offer.

Medicare Part DMedicare Prescription Drug Coverage (Medicare Part D) isan optional program for beneficiaries. There are two ways toreceive this benefit. First, the beneficiary can opt into aMedicare Part C program that offers a medication benefit.Second, the beneficiary can opt to enroll in the Medicare Part D program, which generally requires a monthly pre-mium. More information on the Medicare Prescription DrugCoverage program can be found at the Medicare Web site(www.medicare.gov) or by calling 1-800-MEDICARE.

Medicare Supplemental InsuranceMedicare supplemental insurance, commonly referred to asMedigap, is additional private insurance that covers certainMedicare deductibles, copayments, and out-of-pocketexpenses. This private insurance is federally regulated byCongress to avoid fraud or abuse of those beneficiaries they

insure. The costs in any Medigap Plan A through L are thesame for any insurance company; however, the costs to thebeneficiary may vary (CMS, 2006a).

PHYSICIAN FEE SCHEDULE AND CODINGMedicare Part B occupational therapy services are reim-bursed under the Medicare PFS. The PFS sets the paymentfor each billing code. Legislation established a payment sys-tem for services delivered across service providers based ongeographic regions. The Resource Based Relative Value Scaleis the system for measuring physician and provider input inmedical services for the purpose of calculating a PFS. Therelative value unit (RVU) is the standard for measuring thevalue of medical services provided by the health careprovider compared with other medical services provided byother health care providers. The RVU for each service hasthree components: work, practice, and malpractice. The work component represents skilled time spent for setting up,preparing for, and delivering the service. For occupationaltherapy codes, this component represents 55% of the totalcode value. Considerations in defining the work componentvalue include the technical skill and physical effort (skill,education, scope of practice intervention), mental effort andjudgment (the complexity of the medical diagnosis, possibletreatment options, medical urgency), and psychologicalstress (the risk of significant complications, morbidity, mor-tality). The practice component makes up approximately40% of the total code value. The practice component includesoverhead expenses of providing the service—including calcu-lations for rent, utilities, office staffing, and equipment andsupplies—that might be apportioned to the delivery of serv-ice. The malpractice component represents professional lia-bility coverage, which is very low in therapy codes.

To establish the PFS (code value), the RVUs (for work,practice, and malpractice expenses) are each multiplied by ageographic adjustment factor (GAF) and the national uni-form Medicare conversion factor (CF). The GAF makesadjustments for geographic location, and the CF converts thegeographically adjusted RVUs to a dollar amount, with con-siderations for inflation. The Medicare PFS can be found onthe CMS Web site (www.cms.hhs.gov/PhysicianFeeSched).

Occupational therapy practitioners must bill for MedicarePart B services using Current Procedural Terminology(CPT™) coding. CPT codes are used to describe the clinicalcontact between the patient and treating clinician. In 1983,CMS adopted CPT coding into a system called HealthcareCommon Procedural Coding System (HCPCS), which con-tains two types of codes: Level I identifies CPT codes, andLevel II represents supplies and equipment. The Level I CPTcodes that CMS accepts are divided into six major categories;occupational therapy practitioners primarily use theMedicine/Physical Medicine and Rehabilitation section codes.

CPT codes are described as timed or nontimed codes. Forcodes calculated by time, the practitioner must consider the

time spent in that procedure when billing the service. Anexample of timed codes includes self-care/home managementand/or training (97535), neuromuscular reeducation (97112),and contrast bath (97034)*. For nontimed codes, only one unitper day can be billed by the occupational therapy practitioner,regardless of the total time spent in providing that service. Anexample of nontimed codes includes occupational therapyevaluation (97003), occupational therapy reevaluation(97004), and unattended electrical stimulation (GO283)*.

When billing Medicare Part B, it is essential to adhere tothe billing guidelines, especially knowing and understandingthe billing requirements and proper application of the “8-minute rule” (see Table 1). All the time spent deliveringtimed codes are aggregated. The aggregated time will estab-

lish how many units of timedcodes can be billed. Units areassigned based on the codesyou spent the most time pro-viding. For examples and fur-ther instructions for assigningunits, refer to Chapter 5 of theMedicare Claims ProcessingManual (CMS, 2006c).

Medicare requires the prac-titioner to record the totalamount of time spent providingtimed codes. The units billedfor timed codes must be con-sistent with the amount of timespent in service. Medicare alsorequires the practitioner torecord the total amount of time

spent delivering both timed and nontimed services. Medicareregulations do not require the therapist to record the amountof time spent delivering each CPT code, just the aggregatedtime (CMS, 2006b).

To avoid inappropriate billing of bundled codes, CMSimplemented a policy in 1996 known as the Correct CodingInitiative (CCI). The purpose of the CCI is to develop correctcoding methodologies to curtail improper “unbundling” ofservices for Medicare Part B claims. The CCI applies “edits”that are used to review claims and to identify potential misuseand inappropriate billing of code pairs. Beginning January 1,2006, CCI edits applied to all providers billing Medicare PartB. CCI edits are applied to services billed by the sameprovider for the same beneficiary on the same date of service.If you are billing in an SNF, a CORF, or a rehabilitation agencyusing a single provider number for all therapies, the edits willapply among disciplines (occupational therapy, physical ther-

apy, speech-language pathology). For example, if you work inan SNF and the physical therapist provides gait training(97116) to Mrs. Smith on the same day the occupational ther-apist provides her with therapeutic activities (97530), thesecodes are edited and the physical therapist would need tomodify the gait training code (97116) to get paid. Based onthe CCI edit rules, a modifier (“-59”) can be applied to thecode when services are distinctly different and permitted tobe billed together. The previous example is a good demonstra-tion of two codes billed on the same day using the modifier -59. If you are the sole provider as an independent practi-tioner using your own provider number, other discipline serv-ices do not influence your coding. Therapeutic activities(97530) and self-care/home management (97535) are exam-ples of codes that are considered bundled under the CCI editrules. For these codes to be billed together on the same day,they need to be provided at separate time intervals that weredistinctly different. For example, a patient might receive ther-apeutic activities (97530) for balance training from 1:00 p.m.to 1:15 p.m. and then participate in self-care/home management(97535) for lower-body dressing using adaptive equipmentfrom 1:15 p.m. to 1:45 p.m. These services were distinctly different and can be billed together using the -59 modifier on self-care/home management (97535). It is important toknow the CCI edits because some codes can never be billedtogether on the same day. For example, OT evaluation(97003) and OT re-evaluation (97004) can never be billedtogether on the same day; only one of the two codes would be paid (OT re-evaluation, 97004).

CMS updates the CCI edits code pair list every quarter.CCI edits are available at no cost by downloading them fromthe CMS Web site (www.cms.hhs.gov/physicians/cciedits/default.asp). Note that there are two different types ofNational Correct Coding Initiative (NCCI) edits based on thepractice setting. OTPPs use the NCCI Edits for Physicians.Other practice settings use the NCCI Edits for HospitalOutpatient Prospective Payment System. For more informa-tion on understanding and applying CCI edits go to www.cms.hhs.gov/NationalCorrectCodInitEd.

The second type of coding used to bill for services isHCPCS Level II, which are alpha-number codes that includeequipment and supply codes for dressings (A codes), DME(E codes), orthotics or prosthetics (L codes), and G codes(e.g., unattended electrical stimulation, GO283). To use the Lcodes for billing orthotics, the OTPP or practice setting mustbe a Medicare DME provider with an approved number.Recently, Medicare has required that all suppliers of DME,prosthetics, and orthotics must obtain accreditation by anapproved accreditation organization to obtain reimbursementunder Medicare Part B.

LIMITATIONS ON THERAPY SERVICESThe Balanced Budget Act of 1997 placed annual financial lim-itations on therapy services, known as the “therapy caps.”

Earn .1 AOTA CEU (one NBCOT PDU /one contact hour, see page CE-7 for details)

* Current Procedural Terminology (CPT) is copyright 2006 American MedicalAssociation. All Rights Reserved. No fee schedules, basic units, relative values,or related listings are included in CPT. The AMA assumes no liability for thedata contained herein. Applicable FARS/DFARS restrictions apply to govern-ment use.


Table 1. Counting Minutes for Timed Codes in 15-Minute UnitsNumber Number of Units of Minutes1 –> 8 through 222 –> 23 through 373 –> 38 through 524 –> 53 through 675 –> 68 through 826 –> 83 through 977 –> 98 through 1128 –> 113 through 127

Note. From CMS (2006b).



The therapy caps were in effect in 1999, and briefly in both2003 and 2006. The therapy caps apply to all Medicare Part Bsettings except outpatient hospitals, which are exempt bylaw. In February 2006 Congress passed the Deficit ReductionAct of 2005 (Public Law 109-171), allowing patients toreceive services beyond the $1,740 limitation if they meetspecific criteria. This exception process is either automaticby using a modifier (KX) on the claim when it is billed, ormanual, which requires written communication with the con-tractor for approval.

On December 7, 2006, after significant lobbying efforts bythe therapy community and other stakeholders, the therapycap exception process was extended to apply from January 1,2007 to December 31, 2007, through a provision in H.R. 6111,the Tax Relief and Health Care Act of 2006. As of January 1,2007, the annual financial limitation will be $1,780 for occu-pational therapy services.

MEDICARE DOCUMENTATION To qualify for occupational therapy services under theMedicare benefit, services must be medically necessary. Eachof the Medicare provider settings (e.g., SNF, home health,inpatient hospitalization, outpatient) may have some uniquerequirements for medical necessity or for documentation;however, many of the criteria are similar. Medicare Part B hasthe most prescriptive requirements for documentation, whichhave been revised several times in the past year. For the mostcurrent requirements, refer to Chapter 15 of the MedicareBenefit Policy Manual (CMS, 2006b).

In all cases, the patient must have a condition thatrequires the skills of a therapist. The patient is under thecare of a physician who certifies and recertifies the plan ofcare. A qualified person (e.g., a person qualified to provideoccupational therapy services in that given state) must pro-vide services. The intervention is within an accepted stan-dard of practice for occupational therapy. Services areprovided within a reasonable frequency, intensity, and dura-tion for the condition. There is an expectation that thepatient will improve in a reasonable amount of time.

It is important that as practitioners we clearly document thepatient’s previous level of functioning, current medical condi-tion, functional limitations, and how skilled occupational ther-apy services are necessary to return the patient to his or herhighest practicable level of functioning. Do not assume that themedical reviewer understands the level of sophistication of ourskilled services. Use the following AOTA materials to supportthat the services you are providing are within the standard ofpractice for your profession: standards of practice for occupa-tional therapy, practice guidelines, specialized knowledge andskills papers, and evidenced-based practice resources. Clearlydocument the progress the patient is making toward his or hergoals and the remaining functional limitations and skilled ther-apy needs. Present a clear and concise picture of the patientand the occupational therapy services.

Documentation requirements may vary slightly; however,in general an evaluation and plan of care, certification andrecertification, progress notes, and encounter notes are nec-essary (Brennan & Robinson, 2006). A treatment encounternote is written after each occupational therapy treatmentsession. Medicare requires documentation for every treat-ment day; at a minimum, this documentation identifies theskilled service provided and the identity of the qualified pro-fessional (therapist, assistant) providing the service. Formore information on documentation, refer to your practicesetting’s chapter of the Medicare Benefit Policy Manual;Medicare Part B outpatient services requirements are foundin Chapter 15 (CMS, 2006b).

MEDICARE CONTRACTORS AND DENIALS MANAGEMENTMedicare has private insurance organizations that administerand pay Medicare claims. Currently, Medicare Part A claimsgenerally are administered by fiscal intermediaries; however,home health care is managed by regional home health inter-mediaries. OTPPs, rehabilitation agencies, and outpatientrehabilitation facilities are billed under Medicare Part B,which is administered by a Medicare carrier. DMEPOS arebilled under Medicare Part B DME regional carriers. BySeptember 2011, Medicare administrative contractors willreplace all fiscal intermediaries and carriers; once this changeis completed, there no longer will be a distinction betweenMedicare Part A or B contractors.

Medicare contractors use Medicare program manuals tohelp guide medical review. In addition to these manuals, con-tractors use their own guidelines for medical review calledlocal coverage determinations. To be proactive in the medicalreview process, know the Medicare program manual for yourpractice setting, Medicare National Coverage Decisions(CMS, 2006e), and review your Medicare contractor’s localcoverage determinations. Medicare redesigned the claimsappeal process in 2005; now the claims process is largely thesame for both Medicare Part A and Medicare Part B. Thereare specific time frames for response for each level of appeal;therefore, it is essential to respond immediately to an addi-tional development request and timely to all levels of theappeals (Medicare Program: Changes to the Medicare ClaimsAppeal Procedures, 2005). For more information on docu-mentation and the denial process, refer to Brennan andRobinson (2006).

FUTURE CHANGESMedicare rules and regulations are changed or modified fre-quently. Some changes on the horizon include return to thetherapy cap; pay for performance; competitive bidding; sup-pliers of DMEPOS accreditation; and therapy certification forpower wheeled mobility devices. To follow these issues andother possible changes, refer to the Reimbursement page onthe AOTA Web site for up-to-date information and resources(www.aota.org/members/area5/links/link01.asp).

CONCLUSIONOccupational therapists and occupational therapy assistantswork in the majority of settings that service Medicare benefi-ciaries. These various Medicare programs cover more than 42million individuals. Each of these programs has its own set ofrules, regulations, and requirements. By understanding these requirements we can better serve and advocate for our patients and our profession. Legislation establishes anddrives the Medicare rules, and as practitioners we must beproactive by communicating with our congressional repre-sentatives about issues and concerns regarding Medicare and other related health care legislation. In addition, we mustbe proactive in advocating for Medicare coverage of the fullscope of occupational therapy practice with CMS and its contractors. n

ACKNOWLEDGMENTSI thank the following individuals for their review and contribu-tions to the content of this article: Cathy Brennan, MA, OTR/L,FAOTA; Sharmila Sandhu, Esq.; and Judy Thomas, MGA.

REFERENCESAmerican Occupational Therapy Association. (2004). Scope of practice.

American Journal of Occupational Therapy, 58, 673–677.

American Psychiatric Association. (1994). Diagnostic and statistical manual ofmental disorders (4th ed.). Washington, DC: Author.

Balanced Budget Act of 1997. Pub. L. 105-33, 111 Stat. 251.

Balanced Budget Refinement Act of 1999. Pub. L. 106-113, 113 Stat. 1301.

Brennan, C., & Robinson, M. (2006). Documentation: Getting it right to avoidMedicare denials. OT Practice, 11(14), 10–15.

CCH Editorial Staff Productions. (2006). Medicare explained 2006: Health lawsprofessional series. Chicago: CCH Incorporated.

Centers for Disease Control and Prevention & National Center for HealthStatistics. (2006). International classification of diseases, ninth revision, clini-cal modification. Hyattsville, MD: Author.

Centers for Medicare & Medicaid Services. (2006a). Medicare and you 2007.Retrieved October 20, 2006, from http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf

Centers for Medicare & Medicaid Services. (2006b). Medicare benefit policy man-ual (Publication 100-02). Retrieved November 30, 2006, fromhttp://www.cms.hhs.gov/Manuals/IOM/list.asp

Centers for Medicare & Medicaid Services. (2006c). Medicare claims processingmanual (Publication 100-04). Retrieved November 30, 2006, from http://www.cms.hhs.gov/Manuals/IOM/list.asp

Centers for Medicare & Medicaid Services. (2006d). Medicare general informa-tion, eligibility, and entitlement (Publication 100-01). Retrieved October 20,2006, from http://www.cms.hhs.gov/Manuals/IOM/list.asp

Centers for Medicare & Medicaid Services. (2006e). Medicare national coveragedeterminations manual (Publication 100-03). Retrieved December 8, 2006,from http://www.cms.hhs.gov/Manuals/IOM/list.asp

Deficit Reduction Act of 2005. Pub. L. 109-171, S. 1932.

Kaiser Family Foundation. (2005). Briefing: Medicare basics, from (Part) A to D[Transcript]. Retrieved October 20, 2006, from http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1431

Medicare program: Changes to the Medicare claims appeal procedures: Interimfinal rule, 70 Fed. Reg. 11,420 (Mar. 8, 2005) (to be codified at 42 C.F.R. pt.401 and 405).

Medicare Modernization Act of 2003. Pub. L. 108-173, 117 Stat. 2066.

Social Security Act Amendments of 1965. Pub. L. 89-97, 42 U.S.C. § 1395 et seq.

Social Security Act Amendments of 1983. Pub. L. 98-21, 42 U.S.C. § 1395 et seq.

Tax Relief and Health Care Act of 2006. H.R. 6111. Pub. L. 109-432

.

RESOURCES PublicationsAmerican Medical Association. (2006). AMA HCPCS Level II 2007. Chicago:

Ingenix.

American Medical Association. (2006). AMA physician ICD-9-CM 2007 (Vol. 1 & 2).Chicago: Ingenix.

American Medical Association. (2006). CPT® 2007 professional edition. Chicago:Ingenix.

Centers for Medicare & Medicaid Services. (2006). Revised long-term care facilityresident assessment instrument user’s manual version 2.0 (MDS). Available:http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp

Medicare contractor: www.cms.hhs.gov/apps/contacts

CCI Edits Quarterly UpdatesNational Correct Coding Initiative Edits (Carrier = OTPP, PTPP, and physicians)

www.cms.hhs.gov/physicians/cciedits/default.asp

National Correct Coding Initiative Edits Hospital Outpatient ProspectivePayment System http://www.cms.hhs.gov/providers/hopps/cciedits/default.asp.

Physician Fee Schedules (CPT codes) http://www.cms.hhs.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage

Orthotics/Durable Medical Equipment Regional Carriers Fee Schedulehttp//:www.cms.hhs.gov/center/dme.asp

Earn .1 AOTA CEU (one NBCOT PDU /one contact hour, see below for details)


How To Apply for Continuing Education Credit:1. After reading the article Medicare 101: Understanding the Basics,

answer the questions to the final exam found on p. CE-8 byregistering to take them online and receive your certificateimmediately upon successful completion of the exam. You canstill complete the exam by darkening the appropriate boxes inSection B of the Registration and Answer Card, which is boundinto this issue of OT Practice following the test page. In eithercase, each question has only one answer.

2. To register click on www.aota.org/cea or call toll-free 877-404-2682. Once you are registered, you can log on to www.aota-learning org to take the exam online. If your are using theRegistration and Answer Card, complete Sections A through Dand return the card with the appropriate payment to theaddress indicated.

3. There is a nonrefundable processing fee to score the exam, andcontinuing education credit will be issued only for a passingscore of at least 75%. Use the electronic exam and you canprint your official certificate immediately if you achieve a pass-ing score. If you are submitting a Registration and AnswerCard, you will receive a certificate within 30 days of receipt ofthe processed card.

4. The electronic exam must be completed by February 28, 2009.The Registration and Answer Card must be received byFebruary 28, 2009, in order to receive credit for Medicare 101:Understanding the Basics.

New Electronic Exam:Immediate Results and Certificate

Final ExamMEDICARE 101: UNDERSTANDING THE BASICSFebruary 19, 2007

Learning Level: IntermediateTarget Audience: Occupational Therapist and Occupational

Therapy AssistantsContent Focus: Category 3: Professional Issues, Legal,

Legislative, & Regulatory Issues

Register for the electronic exam and certificate online atwww.aota.org/cea, call toll free 877-404-2682, or use theRegistration and Answer Card bound into this issue of OT Practice following the test page.

1. Medicare is the largest health care payer in the UnitedStates.A. True B. False

2. Congress established Medicare in Title XVIII of the SocialSecurity Act of ___? A. 1941 B. 1950 C. 1965 D. 1970

3. Which of the following does not follow the Medicare PartA program? A. Inpatient hospitalsB. Occupational therapist private practitioners (OTPPs)C. Home healthD. Inpatient rehabilitation facilities

4. OTPPs follow Medicare program A. Part A B. Part B C. Part D D. None of the above

5. The first Medicare PPS was: A. Inpatient (acute) hospitals (DRG) B. Inpatient rehabilitation facilities (IRF-PAI)C. Home health care (OASIS) D. CPT coding

6. Medicare Part B is an optional program.A. TrueB. False

7. Medicare Advantage Plan includes coverage forA. Medicare Part AB. Medicare Part BC. Medicare Parts A & B D. Medicare Prescription Drug Plan only

8. When billing Medicare Part B outpatient occupationaltherapy services, use the following to record and bill yourservice: A. CPT codes B. PPS categories C. ICD-9 codes D. None of the above

9. The following policy is used to prevent unbundling ofCPT codes: A. KX modifier B. CCI edits C. ICD-9 codes D. None of the above

10. Which of the following describes elements of occupa-tional therapy documentation?A. An evaluation/plan of careB. Physician involvementC. Encounter notesD. All of the above

11. Medicare contractors develop guidelines for paying serv-ices; these guidelines are: A. National coverage determinations B. Local coverage determinations C. Regulations D. None of the above

12. Federal legislation establishes Medicare rules.A. TrueB. False



Medicare SNF Requirements

GO TO: http://www.aota.org/News/AdvocacyNews/SNF-Requirements.aspx

CMS Issues Final 2012 SNF PPS Rule

The Centers for Medicare & Medicaid Services (CMS) issued its final Skilled Nursing Facility (SNF) Prospective Payment System (PPS) regulation for fiscal year 2012. Click here to read the final rule. Rulemaking for FY 2012

AOTA submitted comments on the proposed rule on June 27, advocating for a more prominent role for occupational therapists in occupational therapy clinical decision making. We argued that CMS should gather more data and do further analysis before contemplating the proposed drastic payment cuts. We supported the removal of the requirement for line-of-sight supervision of therapy students and urged CMS to promptly revise the RAI Manual to allow time for therapy practitioners and SNFs to adjust their policies. We also recommended that CMS adopt and publicize specific guidance for student supervision that we developed along with APTA and ASHA. AOTA strongly opposed CMS’s proposal to reconfigure the way group therapy minutes are allocated to reduce their value and to redefine group therapy. We made recommendations

regarding assessment requirements to lessen burdensome documentation and base patient assessment on the therapist’s clinical judgment and the individual patient’s condition.

As a resource for members, AOTA’s Public Affairs Division & member experts prepared two podcasts regarding the final rule.

SNF Final Rule, Podcast Part 1 – Recorded September 21, 2011 Topics include the new MDS schedule, group therapy, student supervision, and co-treatment

SNF Final Rule, Podcast Part 2 – Recorded September 28, 2011 Topics include EOT OMRA & new Resumption items and the new PPS assessment COT OMRA

Resources on Rulemaking for FY 2012

SNF Final Rule, Podcast Part 1 – Recorded September 21, 2011

SNF Final Rule, Podcast Part 2 – Recorded September 28, 2011

AOTA Analysis: Final Skilled Nursing Facility PPS Rule for FY 2012 FY 2012 SNF PPS Transition Policy Memo

SNF PPS Final Rule for FY 2012

AOTA Submits Comments to CMS regarding Proposed SNF PPS Rule for 2012

CMS Issues Proposed SNF PPS Rule for FY 2012

SNF PPS Proposed Rule for FY 2012

CMS Announces 2012 Minimum Data Set (MDS) 3.0 National Conference – March 2012 – St. Louis, Missouri

CMS National Provider Call: MDS 3.0 Changes Relating to SNF PPS Final Rule

August 23, 2011 National Provider Call Follow-Up and Clarifications November 3, 2011 National Provider Call Slides

August 23, 2011 National Provider Call Slides

August 23, 2011 National Provider Call Transcript

Rulemaking for FY 2011

SNF Changes Effective 10-1-10

AOTA Comments on Proposed SNF PPS Rule for FY 2011

CMS SNF Resources

RAI Manual, available in a zip file on the CMS web site at www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp -- under “Downloads”; See Chapter 3, Section O for Therapies

CMS Skilled Nursing Facility Center

CMS SNF PPS Payment Fact Sheet

Medicare Benefit Policy Manual - Coverage of Extended Care (SNF) Services Under Hospital Insurance

Medicare Benefit Policy Manual - Covered Medical and Other Health Services (See Sections 220 & 230 for Occupational Therapy)

CMS Skilled Nursing Facility/Long-Term Care Open Door Forum

Additional Resources

OT/OTA Student Supervision & Medicare Requirements

OIG Releases Reports Regarding SNFs

Occupational Therapy's Role in Skilled Nursing Facilities

Skilled Nursing Facilities Chapter in March 2012 MedPAC Report to Congress

MedPAC Comment Letter re. Proposed SNF PPS Rule for FY 2012

MedPAC SNF Services Payment System


MedPAC Comment Letter re. Proposed SNF PPS Rule for FY 2011


Occupational Therapy:

Living Life To Its Fullest®

800-377-8555 TDD

www.aota.org

301-652-2682

301-652-7711 fax

4720 Montgomery Lane

Bethesda, MD 20814-1220

AOTA Analysis: Final Skilled Nursing Facility PPS Rule for FY 2012 The Centers for Medicare & Medicaid Services (CMS) published the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) final rule for fiscal year 2012 in the August 8, 2011, Federal Register. The final rule addresses 2012 SNF payment rates, as well as student supervision, group therapy coverage and documentation requirements, the Minimum Data Set Version 3.0 (MDS 3.0) assessment schedule, and Other Medicare-Required Assessments (OMRAs). Rate changes and policy revisions will go into effect October 1, 2011. AOTA was invited to participate in a limited briefing with CMS officials when the rule was announced on July 29, 2011. The briefing indicated that the rule was essentially adopted as proposed, which may have negative consequences for the SNF industry. AOTA also organized and participated in a CMS briefing for the professional therapy associations. AOTA will update members as we work with CMS and SNF industry members preparing for implementation of the new rule, including providing CMS with ideas for topics for a Medicare Learning Network (MLN) Matters article to help providers understand provisions in the final rule. AOTA will continue to analyze the new policies to monitor their impact and guide our ongoing advocacy efforts. Please e-mail [email protected] to let us know how you are implementing the new requirements and what issues you are facing as a result of the regulation. We will prepare additional materials as needed. SNF PPS Rates CMS is reducing Medicare SNF PPS payments in FY 2012 by $3.87 billion, which means that FY 2012 payments will be 11.1% lower than payments for FY 2011. CMS reports that the FY 2012 rates are intended to correct for an unintended spike in payment levels that resulted from the implementation of RUG-IV and the FY 2011 parity adjustment. CMS is now recalibrating the case-mix indexes (CMIs) for FY 2012 to restore overall payments to their intended levels on a prospective basis. The SNF PPS uses a resource classification system known as Resource Utilization Groups Version 4 (RUG-IV), which assigns a patient to a RUG group to determine a daily payment rate. Each RUG group consists of CMIs that reflects a patient’s severity of illness and the services that a patient requires in the SNF. In transitioning from the previous classification system to the new RUG-IV, CMS adjusted the CMIs for FY 2011 based on forecasted utilization under this new classification system to establish parity in overall payments. SNFs have been paid under RUG-IV since Oct. 1, 2010. CMS found that the parity adjustment made in FY 2011, which was intended to ensure that the new RUG-IV system would not change overall spending levels from the prior

http://www.gpo.gov/fdsys/pkg/FR-2011-08-08/pdf/2011-19544.pdf


AOTA Analysis: Final Skilled Nursing Facility PPS Rule for FY 2012 p. 2

year, instead resulted in a significant increase in Medicare expenditures during FY 2011. CMS determined that this increase in spending was primarily due to shifts in the utilization of therapy modes under the new classification system differing significantly from the projections on which the original parity adjustment was based. CMS stated that additional data analyzed by CMS since publication of the proposed rule confirmed the extent of the overpayments that have occurred since implementation of the RUG-IV system. The Office of the Inspector General (OIG) validated the increased expenditure levels in a separate review of SNF payments during the first 6 months of FY 2011. Because these levels were determined to result from changes in therapy utilization, CMS applied the parity adjustment to the nursing CMIs for the RUG-IV therapy groups and not for the non-therapy groups. The FY 2012 recalibration of the CMIs will result in a reduction to skilled nursing facility payments of $4.47 billion or 12.6%. However, this reduction will be partially offset by the FY 2012 update to Medicare payments to SNFs. The update—an increase of 1.7% or $600 million for FY 2012—reflects a 2.7% increase in the prices of a “market basket” of goods and services reduced by a 1% multi-factor productivity (MFP) adjustment mandated by the Affordable Care Act. The combined MFP-adjusted market basket increase and the FY 2012 recalibration will yield a net reduction of $3.87 billion, or 11.1%. For FY 2012, CMS reports that the recalibration will reflect the intent of the new RUG-IV system to pay SNF providers more accurately based on the service needs of Medicare beneficiaries in their care. The adjustment was determined using claims and assessment data from the first 8 months of FY 2011. It will ensure that payments more accurately reflect the resources required to provide care for the range of SNF patients, including those requiring more medically complex care. CMS emphasized that this recalibration removes an unintended spike in payments that occurred in FY 2011 rather than decreasing an otherwise appropriate payment amount. Even with the recalibration, the FY 2012 payment rates will be 3.4% higher than the rates established for FY 2010, the period immediately preceding the unintended spike in payment levels. Further, CMS has not proposed any action to recoup retroactively the excess expenditures already made to SNFs during FY 2011. Instead, CMS limited the scope of the recalibration to restoring the intended SNF PPS payment levels on a prospective basis only, effective October 1, 2011. In the preamble to the final rule, CMS addressed concerns raised by commenters regarding the loss of jobs as a result of the payment changes. CMS stated that since data does not indicate that facilities increased staffing with the implementation of RUG-IV and aggregate payments will return to a level commensurate with those made under RUG-III, CMS does not believe that restoring payment to their intended and appropriate levels should necessarily result in job losses or add significant burden to health care workers or states.


In addition, CMS addressed concerns that applying the recalibration along with other policy changes such as allocation of group therapy and changes to the MDS 3.0 would result in a “double hit” on facilities. CMS responded that due to the ability of facilities and stakeholders to adapt quickly to the changes in the SNF system in ways that maintain payments and consistent utilization patterns, CMS does not believe it would be appropriate to attempt to consider the potential impact of other policy changes for FY 2012 as part of the FY 2011 recalibration calculation. CMS also rejected the idea of phasing in a recalibration because it would continue to reimburse facilities at levels that significantly exceed intended SNF payments. CMS also responded to comments recommending greater fraud and abuse monitoring. CMS stated that it has increased fraud and abuse monitoring efforts for SNFs and for the Medicare program in general. Further, the OIG has started a review of the increased frequency with which patients are assigned to the highest therapy groups. CMS will continue to work with OIG and with CMS contractors to provide greater monitoring of SNF utilization and reporting trends. Student Supervision CMS finalized its proposal to remove the line-of-sight supervision requirement for students to make it consistent with other inpatient settings. In other inpatient settings, CMS does not specify supervision requirements. In those other settings, supervision is guided by state and local laws and regulations, and the facility itself determines the level of supervision a student needs. CMS stated:

Therefore, for the reasons outlined in this final rule and in the FY 2012 proposed rule (76 FR 26385 through 26386), we are finalizing our proposed revision to the line-of-sight supervision requirements as they pertain to students in a SNF setting. Accordingly, in this final rule, we are hereby discontinuing the policy announced in the FY 2000 final rule’s preamble requiring line-of-sight supervision of therapy students in SNFs, as set forth in the FY 2012 proposed rule. Instead, effective October 1, 2011, as with other inpatient settings, each SNF will determine for itself the appropriate manner of supervision of therapy students consistent with state and local laws and practice standards. We will be monitoring student participation in SNFs and expect that facilities will ensure that students, though no longer required to be under line-of-sight supervision, will still be properly supervised for both the student’s and patient’s benefit.

In the final rule, CMS referenced detailed supervision guidelines provided by trade associations. CMS recognized the guidelines as playing a significant role in helping to define the applicable standards of practice on which providers rely in this context. CMS posted the guidelines, including the recommended from AOTA, on its Web site. Members may access this new resource from AOTA which details student supervision requirements across Medicare settings, include the new rules for SNFs.

http://www.aota.org/Practitioners/Reimb/Pay/Medicare/FactSheets/Medicare-Coverage-of-Services.aspx?FT=.pdf


CMS’ current student supervision requirements are included in the RAI Manual for the Minimum Data Set, Version 3.0 (MDS 3.0). See www.aota.org/News/AdvocacyNews/SNF-Students.aspx?FT=.pdf for the current requirements. CMS confirmed that the proposed change to student supervision would require CMS to revise the RAI Manual. AOTA will work with CMS as it revises the RAI Manual. Group Therapy Policy CMS finalized its proposals regarding group therapy. Effective October 1, 2011, CMS will define group therapy as therapy provided simultaneously to four patients (regardless of payer source) who are performing the same or similar activities and are supervised by a therapy (or assistant) who is not supervising any other individuals. CMS will allocate group therapy minutes in same manner as concurrent therapy, based on four patients in a group:

We are finalizing our proposed policies related to group therapy effective October 1, 2011. First, we are defining group therapy as therapy provided simultaneously to four patients (regardless of payer source) who are performing the same or similar activities and are supervised by a therapist (or assistant) who is not supervising any other individuals (76 FR 26386 through 26387). In addition, we are finalizing our proposed policies related to the reporting and allocation of group therapy minutes as discussed above and in the FY 2012 proposed rule (76 FR 26387). As is currently the procedure, the SNF will report the total unallocated group therapy minutes on the MDS 3.0. In terms of RUG–IV classification, this total time will be allocated (that is, divided) among the four group therapy participants to determine the appropriate number of RTM and, therefore, the appropriate RUG–IV therapy group and payment level, for each participant. In addition, as discussed above, if one or more of the four group therapy participants are unexpectedly absent from a session or cannot finish participating in the entire group session, rather than discontinuing payment or requiring the session to be rescheduled, we will continue to deem the therapy session as meeting the definition of group therapy as long as the therapy program originally had been planned for four patients. In this situation, we will continue to assume that there are four patients, and therefore will divide the therapy minutes by four in allocating group therapy minutes among the group therapy participants. (76 Fed. Reg. 48517)

Current Policy: Under a Part A SNF stay, groups for therapy can consist of 2 to 4 people interacting with each other as they perform the same or similar activities. All minutes that the patient is in the group activity are recorded on the MDS (e.g., if a group lasts 60 minutes, the MDS would reflect 60 minutes of group therapy for each person in the group). Also in current policy, there is a limit on the amount of group therapy that can be counted as minutes to determine RUG classification. Group therapy cannot comprise more than 25% of the total weekly therapy minutes for each patient.

www.aota.org/News/AdvocacyNews/SNF-Students.aspx?FT=.pdf


CMS stated that following last year’s policy changes, there was a major decrease in the amount of concurrent therapy performed in SNFs and a significant increase in the amount of group therapy services. CMS believes that allocating concurrent therapy minutes and not group therapy minutes may have created an inappropriate payment incentive to perform group therapy in place of individual or concurrent therapy. New Policy Effective October 1, 2011: For any assessments with an ARD on or after October 1, 2011, group therapy minutes will be allocated regardless of whether the look back period extends prior to October 1, 2011. CMS will allocate minutes of group therapy based on a group size of four patients. CMS believes that a four-person group is the most effective group size and stated, “We believe that groups of fewer than four participants do not maximize the group therapy benefit for the participants.” In situations where the definition of group therapy is not met, those minutes cannot be coded on the MDS as group therapy. The minutes of therapy time will be counted based on the therapist’s time rather than the time the patient spends receiving therapy. CMS believes that when a therapist treats four patients in a group for an hour, it does not cost the SNF four times the amount (or four hours of a therapist’s salary) to provide those services. Therefore, CMS believes that allocating group therapy minutes among the four group therapy participants would best capture the resource utilization and cost. CMS will allocate “reimbursable therapy minutes (RTM)” as a method to classify patients into RUG-IV categories. RTMs will be based on the therapist’s time, as opposed to the patient’s time, in the group. CMS will allocate minutes based on a four-person group, regardless of number of people that actually participated. For example, if a group is scheduled for 60 minutes, each person will receive 15 minutes of therapy time on the MDS. This will be true even if one or more people are unable to attend. The 25% of total therapy per week per patient policy remains unchanged, as CMS continues to believe that group therapy should serve only as an adjunct to individual therapy. CMS expects group therapy to be a structured, planned program with four participants for whom group therapy has been determined appropriate. CMS believes that group therapy sessions should not fluctuate in size or membership. CMS acknowledged that it was not able to find research data to support any prescribed number of participants in a therapy group, but maintained its position that four participants is the optimal number. In response to comments, CMS stated that it does not believe that the allocation of group therapy minutes should be considered a deterrent to having group therapy sessions or should negatively affect beneficiaries. CMS emphasized that it expects therapists to continue to provide the mode of therapy that is most clinically appropriate for each patient. CMS will continue to monitor group therapy utilization and will continue to consult with clinical experts, professional therapy associations, and other stakeholders on this issue. Therapy Documentation CMS finalized its clarification of documentation requirements for group therapy documentation. CMS requires that therapy documentation justify the use of individual,


concurrent, or group therapy and include ongoing support based on the patient’s needs and goals. Under current Medicare requirements, a patient’s plan of care must prescribe the type, amount, frequency, and duration of physical therapy, occupational therapy, or speech-language pathology services. CMS expects each patient’s plan of care to include ongoing supporting documentation and indicate the diagnosis and anticipated goals. CMS stated in the proposed rule that this clinical documentation has always been necessary to identify when significant changes in a patient’s medical condition occur. It is also required so that contractors can verify medical necessity when they review SNF claims. CMS adopted clarifications to its expectations for clinical documentation needed to support each patient’s plan of care, including group therapy interventions. Clinical documentation, including the patient’s medical record, therapy notes, and/or other related documentation, must demonstrate how the prescribed skilled therapy services contribute to the patient’s anticipated progression toward the prescribed goals. The plan of care must include an explicit justification for the use of group, rather than individual or concurrent, therapy. This description should include, but not be limited to, the specific benefits to that particular patient including the documented type and amount of group therapy; in other words, how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals. Documentation also needs to include ongoing support based on the patient’s needs and goals. If the use of therapy services deviates significantly from the patient’s original plan of care, the therapist must update the plan of care as well as the patient’s goals. To demonstrate that changes to the mode and/or intensity of therapy are medically necessary, the provider should clearly describe in the plan of care the reasons for deviating from the original care plan. CMS expects that the data reported in both scheduled and unscheduled assessments will provide an accurate representation of the skilled therapy and nursing needs of the patient. If there is a change in clinical and therapy status that affects the accuracy of the resident’s most recent assessment, then CMS expects the changes to be documented and used to determine if they would result in a reclassification of the resident’s case-mix group. MDS 3.0 Assessment Schedule and Other Medicare-Required Assessments CMS adopted the following proposals:

• Modified the current Medicare-required assessment schedule to incorporate new assessment windows and maintain grace days, in order to avoid duplicative assessments and capture changes in the patient’s status

• Clarified that for purposes of setting the Assessment Reference Date (ARD), an End of Therapy (EOT) OMRA must be completed when the patient does not


receive therapy for 3 consecutive days and create End-of-Therapy-Resumption (EOT-R) OMRA

• Eliminated the distinction between 5-day and 7-day facilities for purposes of setting the ARD for the EOT OMRA

• Required weekly assessment of minutes to determine whether patient’s status has changed and create Change of Therapy (COT) OMRA as a new PPS assessment to assign the patient to the appropriate RUG-IV classification and payment if the patient’s status has changed

For SNF PPS, scheduled assessments (5-Day, 14-Day, 30-Day, 60-Day, and 90-Day assessments) must be completed within designated time frames. The therapy portion of the assessment is based on a 7-day look-back at therapy services from an ARD. The ARD is chosen from an assessment window that includes defined days and grace days for each assessment. The amount of skilled, ordered therapy provided in the look-back period determines the RUG category for each corresponding payment period. The MDS coordinator depends on the ongoing documentation provided by the occupational therapist and/or occupational therapy assistant in the record. It is the occupational therapist’s responsibility to ensure that reevaluations and patient progress are properly documented in the record to assist the MDS coordinator in correctly completing the OMRAs. In the final rule, CMS agreed that licensed therapists are to use their clinical judgment to treat patients in the most appropriate manner, and to maintain professional standards while providing all necessary services. CMS believes that the combination of the grace period allowance and observation period could cause MDS assessments to overlap or be too close together to be informative. The assessments are intended to capture changes in the patient’s status. CMS believes that its modifications to the current assessment schedule will avoid duplicating information on assessments and better capture changes in patient status (and related changes in RUG category and payment). CMS believes it will improve patient and provider satisfaction, as well as care quality, because therapists will not have to repeat interview questions within a short amount of time, as sometimes happens now. CMS kept the grace periods in place and encourages the use of grace days if their use will allow a facility more clinical flexibility or will more accurately capture therapy and other treatments. CMS may explore the option of incorporating the grace days into the regular ARD window in the future. CMS does not intend to penalize any facility that chooses to use the grace days for assessment scheduling or to audit facilities based solely on their regular use of grace days.


The current and new MDS 3.0 Assessment Schedules appeared in the proposed rule:

CMS adopted the proposed schedule as it appears above, and it is effective October 1, 2011. Any ARDs set after October 1, 2011, must be in line with the updated assessment schedule. NOTE: When October 1, 2011, is Day 19, 34, 64, or 94 of the stay, assessments should be completed by September 30 or the assessments will be considered late and payment penalties will apply. In addition, CMS clarified that for the purposes of setting the ARD, an EOT OMRA must be completed when the patient does not receive therapy for 3 consecutive days. This is regardless of the reason for discontinuing therapy. CMS eliminated the distinction between 5- and 7-day facilities. Effective October 1, 2011, facilities will be considered 7-day facilities for the purposes of setting the ARD for an EOT OMRA. As October 1, 2011 is a Saturday, this day should be counted as a day of missed therapy if a patient does not receive any therapy services on that day. In response to comments expressing concerns about the elimination of the distinction between 5- and 7-day facilities, CMS stated its primary concern is that SNF residents receive daily skilled rehabilitation. CMS cited § 409.31(b)(1) which requires skilled services on a daily basis, as well as § 409.34(a)(2) which requires skilled services at least 5 days a week to support its policy that a facility must ensure that therapy is provided for at least 5 days a week. CMS believes that this policy appropriately reflects that the frail and vulnerable populations within SNFs require consistent therapy without significant breaks in service. CMS stated that it is the facility’s responsibility to ensure that patients receive ongoing, rather than sporadic, care to promote each patient reaching his or her full potential. If an EOT OMRA is completed and therapy resumes, the SNF may perform a therapy evaluation or complete the optional Start-of-Therapy (SOT) OMRA to re-classify the patient into a therapy RUG-IV group. End-of-Therapy Resumption (EOT-R) OMRA


Providers had suggested to CMS that they should not be required to complete an EOT and SOT OMRA for patients who resume therapy at the same mode and intensity they were receiving before discontinuation of therapy. In response, CMS created an EOT-R OMRA, effective for all EOT OMRA assessments with an ARD on or after October 1, 2011. When a patient does not receive therapy for no more than 5 consecutive calendar days and resumes therapy at the same RUG-IV classification level (mode & intensity) as before, then the provider may complete an EOT-R. CMS added two new items (O0450A and O0450B) to the EOT OMRA item set so that it can be used as an EOT-R OMRA. The MDS coordinator completes these forms based on therapy documentation and input from the therapist. CMS included the following examples regarding the use of an EOT-R OMRA:

Mr. A. received therapy every day Monday through Friday. He missed therapy on Saturday and Sunday because the SNF he was in did not provide therapy during the weekend. On Monday, Mr. A.’s family came to visit and he refused therapy. At this point, Mr. A. missed 3 days of therapy and an EOT OMRA would be required. He also missed therapy on Tuesday, due to a scheduled doctor’s appointment. The interdisciplinary team made the determination that Mr. A.’s missed therapy did not result in a change in clinical condition that would make him tolerate less therapy and change his RUG–IV classification. Therefore, the facility completed an EOT OMRA on Monday indicating that therapy had not occurred for at least three days. Then, on Wednesday, the EOT is modified into an EOT–R by reporting the actual date of resumption, which was Wednesday. In this case, a new therapy evaluation was not required and Mr. A resumed therapy on Wednesday at the same RUG–IV classification level.

In cases where the patient resumes therapy more than 5 consecutive calendar days after discontinuation of therapy services or where the patient resumes therapy at a different RUG classification level (even if it is no more than 5 consecutive calendar days after the date the last therapy service was furnished), an EOT–R OMRA cannot be used. In this case, the facility could either complete an optional SOT–OMRA and new therapy evaluation if therapy resumes, or wait until the completion of the next scheduled PPS assessment to classify the resident into a RUG–IV group. If the facility chooses not to complete an SOT OMRA and if the next scheduled PPS assessment is used to classify the patient into a therapy RUG group, a new therapy evaluation would also be required.

For example: Mr. B. received therapy every day Wednesday through Monday. On Tuesday, he felt ill and missed therapy that day and Wednesday. He then went to dialysis on Thursday and missed therapy that day as well. He missed a total of 3 days of therapy. Due to his illness and dialysis, he could not immediately resume therapy at the same level he was receiving prior to the three missed days. However, on Friday he felt well enough to start therapy again. The facility completed an EOT OMRA on Thursday to classify Mr. B. into a non-rehabilitation RUG group and to get paid the non-rehabilitation RUG rate for


Tuesday, Wednesday, and Thursday. As Mr. B. could not resume therapy at the same RUG–IV classification level, a new therapy evaluation was completed by each discipline (physical therapy, occupational therapy, and/or speech therapy) treating Mr. B. and then an SOT OMRA was completed, and he was placed back into a rehabilitation RUG group. The facility was paid at the rehabilitation RUG rate from the day therapy restarted until the next PPS assessment was completed.

Advance Beneficiary Notice (ABN) and Notice of Medicare Non-coverage (NOMNC) CMS discussed Advance Beneficiary Notices (ABNs) in the proposed rule. Providers had asked whether they need to issue an ABN every Friday to anticipate the possibility that a resident might be unable or unwilling to do therapy on Monday (which would require an EOT OMRA). In the proposed rule, CMS advised providers that the decision to issue an ABN is individualized and should not be applied across the board to all patients. CMS said it is not appropriate to issue ABN until therapy is discontinued. CMS received comments requesting additional guidance about the use of ABNs and the NOMNC. CMS responded that the policies for issuance of the SNF ABN and an NOMNC have not changed. CMS referred providers to the current manual instructions in the Medicare Claims Processing Manual, IOM 100-04, Chapter 30, Section 70 (see https://www.cms.gov/manuals/downloads/clm104c30.pdf). CMS indicated that if SNF covered services end solely because a beneficiary fails to meet the consecutive days of therapy requirement either because therapy is not offered on those days or the beneficiary refuses or declines therapy, or any combination of those reasons, a NOMNC would not be issued. An NOMNC is not issued when a beneficiary initiates the end of care, or when care ends for provider business reasons, such as when a SNF does not offer therapy on certain days. CMS will publish guidance on NOMNC delivery in the Medicare Claims Processing Manual in the near future and will also include further clarification on NOMNC delivery in other vehicles such as CMS Open Door Forums, as deemed necessary. Change of Therapy (COT) OMRA CMS found that sometimes therapy services recorded in a PPS assessment do not provide an accurate account of the therapy provided to a patient outside the observation window used for the most recent assessment because changes may not rise to the level of a significant change in clinical status and therefore generate an unscheduled assessment. As a result, CMS created a COT OMRA. Whenever the intensity of therapy changes to a degree that no longer reflects the RUG-IV classification and payment assigned to the patient based on the most recent assessment, the SNF must complete a COT OMRA. This applies whether the change in RTM is a scheduled change or an unscheduled or unplanned change, and whether the different RUG category is higher or lower than the RUG category in which the resident is currently placed.


The COT OMRA is completed using the same item set as the current EOT OMRA. The ARD of the COT OMRA would be set for Day 7 of a COT observation period, which is a successive 7-day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (or beginning the day therapy resumes in cases where an EOT–R OMRA is completed), and ending every 7 calendar days thereafter. The provider must assess the patient’s RTMs every 7 days to determine whether they need to do a COT OMRA. The COT OMRA requirements, including the COT observation period requirement, also apply in cases where a resident is receiving therapy but is classified into a nursing RUG because of index maximization. The COT OMRA requirements are effective for all assessments with an ARD on or after October 1, 2011. CMS believes the COT OMRA will allow them to track changes in the patient’s condition and in the provision of therapy services more accurately, allowing reimbursement to reflect resource use more accurately, thereby improving the accuracy of reimbursement. Being able to track these changes will also enhance a SNF’s ability to provide quality care to residents. CMS received comments of concern about the changes to assessment schedules. CMS is confident that these changes allow sufficient time to perform all required assessments, allow for flexibility in scheduling the assessments, and provide a more accurate method for determining payment across the entire 30-day period. CMS will update the RAI Manual to incorporate the changes and instructions for assessments and will provide training opportunities prior to the October 1, 2011 implementation. CMS stated that it will monitor the effects of the changes and make any necessary modifications through future rulemaking. Additional Resources CMS FY 2012 SNF PPS Transition Policy Memo CMS Press Release: CMS Announces More Accurate FY 2012 Payments for Medicare Skilled Nursing Facilities CMS Final SNF PPS Rule AOTA Comments on Proposed SNF Rule AOTA Analysis of Proposed SNF PPS Rule AOTA Notice and Overview of Proposed Rule SNF PPS Proposed Rule in the Federal Register

https://www.cms.gov/SNFPPS/Downloads/fy12transpolicymemo.pdf

https://www.cms.gov/apps/media/press/release.asp?Counter=4030&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

https://www.cms.gov/apps/media/press/release.asp?Counter=4030&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date


http://www.aota.org/News/AdvocacyNews/SNF-PPS-Comments.aspx?FT=.pdf

http://www.aota.org/News/AdvocacyNews/SNF-PPS.aspx?FT=.pdf

http://www.aota.org/News/AdvocacyNews/SNF-Proposed-Rule-FY2012.aspx



OIG Report: Changes in SNF Billing in FY 2011 CMS Chart: Therapy Minutes by Mode for Different Ownership Status Types RUG-III and RUG-IV Distribution of Service Days Based on FY 2011 data Determining RUG-III Group Distribution Based on MDS 3.0 Data CMS Student Supervision Guidelines OT/OTA Student Supervision & Medicare Requirements Practice Advisory: Services Provided by Students in Fieldwork Level II Settings Comparison of Expected versus Actual RUG-IV Utilization MDS 3.0 RAI Manual. For therapy coding instructions and guidance on the use of aides and students, as well as modes of therapy, see the MDS 3.0 RAI Manual document at the bottom of the Web page and go to Chapter 3, Section O, in the zip file. CMS SNF PPS Updates & Recent Data CMS SNF PPS Web Site Everything You Need To Know if You Work in a SNF For more information, see www.aota.org or contact us at [email protected].

http://oig.hhs.gov/oei/reports/oei-02-09-00204.asp

http://www.cms.gov/SNFPPS/Downloads/TherpMinModeOwnerType.pdf

http://www.cms.gov/SNFPPS/Downloads/RUG-III_vs_RUG-IV_DOS_full.pdf

http://www.cms.gov/SNFPPS/downloads/Converting_MDS3_to_RUGIII_05-17-11.pdf

https://www.cms.gov/SNFPPS/Downloads/student_supervision_guidelines.zip

http://www.aota.org/Practitioners/Reimb/Pay/Medicare/FactSheets/Medicare-Coverage-of-Services.aspx?FT=.pdf

http://www.aota.org/Educate/EdRes/Fieldwork/StuSuprvsn/Practice-Advisory-Services-Provided-by-Students-in-Fieldwork-Level-II-Settings.aspx?FT=.pdf

https://www.cms.gov/SNFPPS/Downloads/Exp_vs_Act_RUG4_8mos_Final.pdf

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

https://www.cms.gov/SNFPPS/02_Spotlight.asp

http://www.cms.gov/SNFPPS

http://www.aota.org/news/advocacynews/snf10-1-10.aspx

6 AUGUST 8, 2011 • WWW.AOTA.ORG

c A p I T A l B r I e f I N g

he Centers for Medicare & Medicaid Services (CMS) published its pro-posed Skilled Nursing Facility (SNF) Prospective Payment System (PPS) rule for fiscal year 2012 in the May 6, 2011, Federal Register. The proposed rule includes changes that affect occupational therapy practitioners who provide therapy to Medicare Part A patients in SNFs and reflects CMS’ focus on controlling SNF payment growth. At press time, the final rule was expected by early August and will be effective October 1, 2011. The upcom-ing changes present an opportunity for occupational therapists and occupa-tional therapy assistants to step up and have a stronger voice in appropriately meeting the therapy needs of their clients.

OCCUPATIONAL ThERAPISTS’ CLINICAL JUDGMENT IS KEyMajor provisions in CMS’ proposed rule address areas where client care should rely on the clinical judgment and reasoning of the therapist, with input from the occupational therapy assis-tant. CMS appears to be saying that therapists have not been in the driver’s seat in determining therapy minutes according to real client need. See AOTA’s analysis of the proposed rule and comment letter to CMS, both of which are available to AOTA members at http://aota.org/news/advocacynews/snf10-1-10. Also see the Capital Brief-ing article in the June 20, 2011, issue.

AOTA strongly supports CMS’ proposal to remove the line-of-sight supervision requirement for students. If implemented, this will allow the super-vising therapist/assistant to determine when a student is ready to appropri-ately provide services. More informa-

tion about Medicare rules related to student services is available at http://aota.org/educate/edres/fieldwork/stusuprvsn.

CMS raised concerns about the alleged overuse of group therapy and included proposals to restrict group therapy to four participants and divide the minutes by four rather than giving each individual credit for the full time in therapy. Although AOTA opposes limiting group size and dividing minutes, it does support the proposed rule’s appropriate emphasis on the role of the therapist in evaluation, develop-ing an effective plan of treatment for each SNF resident, and being respon-sible for supporting decisions regarding mode of therapy in documentation. Under these rules, group therapy may not be used unless the therapist has determined and documented in the plan of care that it is appropriate. AOTA’s position is that the mix of indi-vidual, concurrent, and group therapy for each client should be determined by the therapist relying on his or her clinical judgment. In comments, AOTA urged CMS to further acknowledge the importance of the clinical decision-making role of therapists by allowing therapists to determine the appropriate size of a group based on the individual abilities and goals of each client. AOTA also supports CMS’ proposal to require that therapy documentation justifies the use of individual, concurrent, or group. The clinical decision making and evaluation by the occupational thera-pist must be what drives any changes to therapy plans of care or Resource Utilization Group (RUG) categorization.

Additionally, AOTA cited CMS material from 1999 to support the Association’s view that CMS should

count client time instead of therapist time. AOTA argued that the proposed allocation of group therapy minutes discounts the value of the time a therapist spends on each client for evaluation, clinical analysis, group program development, communication with family members and caregivers, team meetings, and documentation for the individual plan of care. AOTA’s Commission on Practice was consulted as these positions were crafted.

In its further efforts to control therapy utilization and ensure appro-priate RUG categorization, CMS pro-posed significant changes to resident assessment schedules. AOTA argued that the occupational therapist must be responsible for evaluating the need for occupational therapy, and that the evaluation should be driven by the therapist’s clinical judgment and the individual client’s condition. The thera-pist should determine when there is a change in the client’s status that affects therapy utilization.

STAND UP FOR yOUR PROFESSIONWe hear from practitioners who are concerned about the level of influ-ence they have on decisions about client care, RUG categorization, and productivity. In these comments, AOTA is working to help you stand up for your professional principles and support your fellow therapists. Your clinical judgment should drive therapy decisions and treatment. Things are changing in the Medicare payment cli-mate—be part of a positive change! n

Jennifer Bogenrief is AOTA’s senior regulatory ana-

lyst in the Reimbursement and Regulatory Policy

Department. She can be reached at jbogenrief@

aota.org.

TAdvocating for Appropriate

Occupational Therapy in SNFsJennifer Bogenrief

Joint Guidelines for Therapy Co-treatment under Medicare

The American Speech-Language-Hearing Association (ASHA)

The American Occupational Therapy Association (AOTA)

The American Physical Therapy Association (APTA)

Co-treatment may be appropriate when practitioners from different professional disciplines can effectively address their treatment goals while the patient is engaged in a single therapy session. For example, a patient may address cognitive goals for sequencing as part of a speech-language pathology (SLP) treatment session while the physical therapist (PT) is training the patient to use a wheelchair, or a patient may address ADL goals for increasing independence as part of an occupational therapist (OT) treatment session while the PT addresses balance retraining with the patient to increase independence with mobility.

• Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience.

• Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.

• Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made.

• Co-treatment should be limited to two disciplines providing interventions during one treatment session.

Clinical Examples:

1. An 86 year-old male with history of high blood pressure and cholesterol, and pacemaker, fell down the stairs at his home and sustained a subdural hematoma. The fall resulted in moderate right sided hemiparesis with difficulty swallowing and expressive aphasia. He was transferred to a skilled nursing facility with goals to include balance and motor retraining exercises, strengthening exercises, transfer training and wheelchair management skills, maximizing independence in ADLs, and improved functional comprehension and swallowing function with vital signs monitored during activity. The PT and SLP perform co-treatments that include the following: The SLP provides strategies to help the patient with following multi step directions to perform exercises while the PT works with the patient on motor sequencing and motor activity. The PT adapts seating for the patient taking into consideration best positioning to optimize facilitation of swallowing interventions by the SLP.

2. A 66 year old female status post ischemic stroke with resulting severe hemiparesis on the left side was admitted to an inpatient rehabilitation facility 3 days ago from the acute care hospital. She has hypertension, diabetes and is obese. She was previously independent in all activities and working part time outside of the home. She lives alone in a single level house. The patient is being seen by PT and OT. Among her many rehabilitation goals are: to increase sitting balance to perform self care, independence in transfers from bed to wheelchair to toilet, and ambulation with assistive devices. The PT and OT perform co-treatments that include the following: PT facilitates weight shift and balance training in a sitting position while the OT works on upper extremity dressing strategies and techniques which require trunk stability. PT works on bed mobility from supine to sitting and transfer from the bed to the wheelchair and to the toilet. The OT works on toilet training using adaptive devices and compensatory techniques as well as on dressing and hygiene management skills while the PT facilitates lower extremity weight shift and standing from the toilet.

The PT facilitates balance and weight shifting while standing as the OT works on bilateral fine and gross motor IADL tasks as components of simple meal preparation in the kitchen.

3. A 72 year old male sustained a traumatic brain injury when he skidded on an icy road and collided with a tree while driving home from the grocery store. Prior to the accident, the patient was retired and living in a retirement community with his spouse of 50 years, both functioning independently with all ADLS and IADLs intact. The patient and his wife have expressed a desire for him to return home with environmental adaptations and support services as needed. The patient has a history of mild COPD and a prior right knee replacement. The patient has some residual right-sided paresis and gait disturbance and some difficulty with executive function including self-organization skills and mild memory impairment. He gets short of breath with moderate exertion.

OT and PT provide co-treatment in a ADL kitchen with PT providing verbal and tactile cuing with gait training to facilitate safe functional mobility in and around kitchen, while OT works on cognitive/executive function skills needed to gather items for a food preparation task, such as attention to task, remembering items needed, locating items in cupboard, refrigerator, and sequencing steps involved in preparing the snack or meal.

Medicare Part A Home Health Requirements

GO TO: http://www.aota.org/News/AdvocacyNews/Part-A-Home-Health.aspx

CMS Issues Final 2012 Home Health PPS Rule

The Centers for Medicare & Medicaid Services (CMS) issued its final Home Health Prospective Payment System (PPS) regulation for calendar year (CY) 2012. Click here to read the final rule.

Rulemaking for CY 2012 AOTA submitted comments on the proposed rule on September 6, 2011 advising CMS to assess the impact of the recent new assessment schedule before making payment cuts based on perceived overutilization identified under the previous therapy requirements. We supported CMS’ clarification regarding when a continuing need for occupational therapy allows for a patient’s continued eligibility and urged CMS to add specific examples to the Medicare Benefit Policy Manual and to educate agencies about this policy to reduce confusion. In addition, we recommended that CMS continue to evaluate the effectiveness of the recent therapy assessment schedule in regards to patient access as well as administrative burden. We advocated that unfettered clinical reasoning and judgment of the therapist should determine a patient’s individual therapy needs.

CMS released its final Home Health Prospective Payment System (PPS) regulation for CY 2012 on November 4, 2011. CMS updated home health PPS rates for home health agencies effective January 1, 2012. Payments are estimated to decrease by approximately 2.31% or $430 million in CY 2012. CMS provided further clarification of the occupational therapy policy regarding when occupational therapy would be considered a dependent service versus when it would be considered a qualifying service under the Medicare home health benefit. Click here to read AOTA's analysis of the final rule.

Click here to access AOTA's Home Health PPS Podcast with Member Experts. (recorded 2/13/12)

Resources on Rulemaking for CY 2012

AOTA Home Health PPS Podcast with Member Experts (recorded 2/13/12)

AOTA Analysis: Final 2012 Home Health PPS Rule

CMS Issues Final Home Health PPS Rule for 2012

CMS Press Release: CMS Finalizes 2012 Medicare Home Health Payment Changes

CMS Final Home Health PPS Regulation for 2012

Medicare Part A Home Health Requirements

AOTA Comments on 2012 Proposed Home Health PPS Rule for 2012

AOTA Analysis: Proposed Home Health PPS Rule for CY 2012

CMS Issues Proposed Home Health PPS Rule for 2012

CMS Home Health PPS Proposed Rule for CY 2012

CMS Press Release: CMS Proposes 2012 Medicare Home Health Payment Changes

Rulemaking for CY 2011

CMS’ Home Health PPS final rule for CY 2011 addressed 2011 home health payment rates, as well as therapy coverage and documentation requirements. CMS delayed implementation of some therapy provisions to April 1, 2011. Rate changes and most other provisions went into effect January 1, 2011. The following resources provide information about the rule requirements for occupational therapy practitioners, specifically about reassessments and documentation.

AOTA Guidance for Completing Functional Reassessments and Documentation in Medicare Home Health

AOTA Home Health Documentation Guide

Additional Resources for CMS Home Health Rule

CMS Transmittal 144 – Revisions to Medicare Policy Manual – Home Health Therapy Services (replacing CMS Transmittal 142)

CMS Transmittal 142 - Revisions to Medicare Policy Manual- Home Health Services

CMS Therapy Requirements Fact Sheet

AOTA Analysis: Final 2011 Medicare Home Health PPS Rule

Final Home Health Rule Issued

CMS Final Home Health PPS Rule (see pages 19-27 for therapy clarifications) AOTA Comments on Proposed Home Health Rule

CMS Home Health PPS Proposed Rule for CY 2011

Background on Proposed Rule

CMS Home Health Resources

CMS Therapy Questions & Answers

CMS Home Health Agency Center

Medicare Benefit Policy Manual - Home Health Services

Medicare Benefit Policy Manual - Covered Medical and Other Health Services (See Sections 220 & 230 for Occupational Therapy)

CMS Home Health, Hospice, DME Open Door Forum

Additional Resources OT/OTA Student Supervision & Medicare Requirements

AOTA Fact Sheet re. OT and Home Health Care

OASIS-C Announcement

Home Health Care Services Chapter in March 2012 MedPAC Report to Congress

MedPAC Comment Letter re. Proposed Home Health Rule for 2012

MedPAC Home Health Care Services Payment System

Home Health Services Chapter in March 2011 MedPAC Report to Congress

MedPAC Comment Letter re. Proposed Home Health Rule for 2011

Home Health Services Chapter in March 2010 MedPAC Report to Congress



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AOTA Analysis: Final Home Health PPS Rule

CMS Clarifies that there Is No Requirement for All Occupational

Therapy Services to be followed by a Skilled Service The Centers for Medicare & Medicaid Services (CMS) published the final Home Health Prospective Payment System (HH PPS) regulation for calendar year 2012 in the November 4, 2011, Federal Register. The final rule addresses 2012 HH PPS payment rates, as well as occupational therapy policy clarifications and structural changes to the HH PPS such as lower payments for high therapy episodes. Rate changes and policy revisions will go into effect January 1, 2012. AOTA will continue to analyze the new policies to monitor their impact and guide our ongoing advocacy efforts. Please e-mail [email protected] to let us know how you are implementing the new requirements and what issues you are facing as a result of the regulation. We will prepare additional materials as needed. Occupational Therapy Policy Clarifications Earlier this year, AOTA approached CMS about an ongoing problem of confusion about when occupational therapy is a continuing qualifying service in home health. As a direct result of this AOTA advocacy, CMS proposed to clarify its policy. In the proposed rule, CMS stated that it was proposing to amend the regulation to demonstrate when a continuing need for occupational therapy allows for a patient’s continued eligibility even though occupational therapy becomes the sole skilled service being provided. In the final rule, CMS amended the regulatory text as follows:

§ 409.42 Beneficiary qualifications for coverage of services.

* * * * *

(c) * * *

(4) Occupational therapy services in the current and subsequent certification

periods (subsequent adjacent episodes) that meet the requirements of § 409.44(c)

initially qualify for home health coverage as a dependent service as defined in §

409.45(d) if the beneficiary’s eligibility for home health services has been

established by virtue of a prior need for intermittent skilled nursing care, speech-

language pathology services, or physical therapy in the current or prior certification

period. Subsequent to an initial covered occupational therapy service, continuing

occupational therapy services which meet the requirements of § 409.44(c) are

considered to be qualifying services. The revised language is a significant improvement that provides clarification about CMS’ requirements for occupational therapy to become a continuing qualifying service. Prior to the release of the final rule, AOTA had heard reports that some providers



AOTA Analysis: Final Home Health PPS Rule for 2012 p. 2

believed that all occupational therapy must be followed by another skilled service—this is not the case. The final rule makes it clear that there is no requirement for all occupational therapy services to be followed by a skilled service. Once the initial qualifying service goes in and identifies the need for occupational therapy, occupational therapy begins as a dependent service. After occupational therapy begins, it becomes a continuing qualifying service after the second visit by the initial qualifying service. The clarification will help to ensure coordinated communication among all skilled providers about the needs of the patient. AOTA will continue to work with CMS on this issue, especially as CMS staff develops examples for the Medicare Benefit Policy Manual. Home Health PPS Rates CMS is reducing Medicare home health agency (HHA) payments by an estimated 2.31%, or $430 million, in 2012. This amount takes into account a 1.4% payment update (a $280 million increase), the wage index update ($10 million increase), and a 3.79% case-mix coding adjustment ($720 million decrease). Therapy Utilization and Case-Mix Weight Revision CMS proposed revisions to the case-mix weights in part because of what it believes is overpayment for therapy services due to the growing use of therapy assistants. AOTA urged CMS to gather more data before making its proposed changes to the case-mix weights. We advised that CMS wait to review the data from HH PPS changes implemented in April 2011. Starting in April 2011, CMS required that at defined points during a course of treatment that a qualified occupational therapist must perform the ordered therapy service. CMS also required that records be kept of whether a therapist or assistant provided the service. We recommended that CMS review at least one year of data before implementing additional policy changes. Based on discussion in the proposed rule of therapy utilization and what CMS and the Medicare Payment Advisory Commission (MedPAC) believe to be incentives for agencies to provide more therapy than is needed to maximize payments, CMS revised the case-mix weights by lowering the relative weights for episodes with high therapy and increasing the weights for episodes with little or no therapy. Because CMS was required to do this in a budget-neutral way, it will redistribute some HH PPS money from high therapy payment groups to other HH PPS case-mix groups, such as the groups with little or no therapy. CMS responded to commenter concerns that the costs for therapy assistant services cannot be estimated by only looking at the assistant salary levels but also must include


supervision time by the therapist and other related costs. CMS responded that even given unrecognized costs for therapy assistant services, there would still be an inappropriate overpayment. CMS clarified that the proposed rule did not assume that therapy assistants are inappropriately used in home health care. Rather, CMS’ concern was that the reimbursement rates were too high in comparison to the actual costs incurred by providers, including costs related to recent shifts in the labor mix for therapy. CMS is gathering more data and will continue to monitor the data. CMS indicated in the final rule that it may further implement changes to the weights in future rulemaking. AOTA will continue to press CMS to ensure that occupational therapy assistant services are a valued part of therapy. Clarification to Medicare Benefit Policy Manual Language on “Confined to the Home” Definition CMS adopted revisions to the definition of “confined to the home.” CMS addressed concerns about a patient’s occasional absences from the home for nonmedical purposes and stated that such absences are allowed if they are infrequent or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. CMS finalized the following revisions to Section 30.1.1 of the Chapter 7 Home Health Benefit Policy Manual:

‘‘30.1.1—Patient Confined to the Home.’’

For a patient to be eligible to receive covered home health services under both Part

A and Part B, the statute requires that a physician certify in all cases that the patient

is confined to his/her home. For purposes of the statute, an individual shall be

considered ‘‘confined to the home’’ (that is, homebound) if the following exist:

(1) The individual has a condition due to an illness or injury that restricts his or her

ability to leave their place of residence except with: the aid of supportive devices

such as crutches, canes, wheelchairs, and walkers; the use of special transportation;

or the assistance of another person; or if leaving home is medically contraindicated;

and

(2) The individual does not have to be bedridden to be considered “confined to the

home.” However, the condition of the patient should be such that there exists a

normal inability to leave home and, consequently, leaving home would require a

considerable and taxing effort.

If the patient does in fact leave the home, the patient may nevertheless be

considered homebound if the absences from the home are infrequent or for periods

of relatively short duration, or are attributable to the need to receive health care

treatment. Absences attributable to the need to receive health care treatment

include, but are not limited to:


• Attendance at adult day centers, licensed or certified by a state or accredited to

furnish adult day-care services in the state, to receive therapeutic, psychological,

or medical treatment;

• Ongoing receipt of outpatient kidney dialysis; or

• The receipt of outpatient chemotherapy or radiation therapy.

Any absence of an individual from the home attributable to the need to receive

health care treatment, including regular absences for the purpose of participating in

therapeutic, psychosocial, or medical treatment in an adult day-care program that is

licensed or certified by a State, or accredited to furnish adult day-care services in a

State, shall not disqualify an individual from being considered to be confined to

his/her home. Any other absence of an individual from the home shall not so

disqualify an individual if the absence is of an infrequent or of relatively short

duration. For purposes of the preceding sentence, any absence for the purpose of

attending a religious service shall be deemed to be an absence of infrequent or short

duration. It is expected that in most instances, absences from the home that occur

will be for the purpose of receiving health care treatment. However, occasional

absences from the home for nonmedical purposes, for example, an occasional

trip to the barber; a walk or a drive around the block; attendance at a family

reunion, funeral, graduation, or other infrequent or unique event would not

necessitate a finding that the patient is not homebound if the absences are

undertaken on an infrequent basis or are of relatively short duration and do

not indicate that the patient has the capacity to obtain the health care

provided outside rather than in the home. (Emphasis added). CMS added “and” to the end of statement (1) of the two requirements above for homebound status to more clearly convey that to be considered “confined to the home,” the patient must first meet one of the following two requirements. The patient must either need physical assistance leaving the home or leaving is medically contraindicated. If the patient meets one of those requirements, the patient must then also meet the two additional requirements as follows: there must also be a normal inability to leave home and leaving the home must require a considerable and taxing effort. Additional Resources CMS Press Release: CMS Finalizes 2012 Medicare Home Health Payment Changes AOTA Comments on Proposed Home Health PPS Rule AOTA Analysis: Proposed Home Health PPS Rule for FY 2012 HH PPS Proposed Rule in the Federal Register

http://www.cms.gov/apps/media/press/release.asp?Counter=4142&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr

http://www.aota.org/news/advocacynews/comments-on-hh-pps-rule.aspx?ft=.pdf

http://www.aota.org/News/AdvocacyNews/Proposed-HH-Rule-2012.aspx?FT=.pdf



CMS Press Release: CMS Proposes 2012 Medicare Home Health Payment Changes AOTA Overview of Medicare Part A Home Health Requirements March 2011 MedPAC Report March 2010 MedPAC Report CMS Home Health Agency (HHA) Center Background information on home health: http://www.aota.org/News/AdvocacyNews/Guidance.aspx Chapter 7 Home Health Manual Face-to-Face Encounter Provisions (implemented March 10, 2011) For more information, see www.aota.org or contact us at [email protected].

http://www.cms.gov/apps/media/press/release.asp?Counter=4014&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

http://www.aota.org/News/AdvocacyNews/Part-A-Home-Health.aspx

http://www.medpac.gov/documents/Mar11_EntireReport.pdf

http://www.medpac.gov/documents/Mar10_EntireReport.pdf

https://www.cms.gov/center/hha.asp

https://www.cms.gov/transmittals/downloads/R139BP.pdf

6 JANUARY 23, 2012 • WWW.AOTA.ORG

c A p i T A l B r i e f i N g

he Centers for Medicare & Medicaid Services (CMS) published its final Home Health Prospective Payment System (PPS) Rate Update rule for calendar year 2012 in the November 4, 2011, Federal Register. The final rule includes a 2.31% decrease in home health agency payments and clarifica-tions relating to when occupational therapy becomes a continuing qualify-ing service under the home health ben-efit. See AOTA’s analysis of the final rule for further details: www.aota.org/News/AdvocacyNews/Final-Home-Health-Rule-Analysis.aspx?FT=.pdf. The final rule took effect on January 1, 2012.

CMS does not require all occupational therapy services to be followed by a skilled service.

The final rule clarifies that after the initial qualifying service (e.g., intermit-tent skilled nursing, physical therapy, speech-language pathology services) identifies the need for occupational therapy, the therapy begins as a dependent service. After occupational therapy begins, it becomes a continu-ing qualifying service after the second visit by the initial qualifying service. CMS included this clarification as a result of advocacy by AOTA members and AOTA staff, after staff received reports that some home health agency administrators have been misinterpret-ing the regulation and discharging patients from the home health benefit when an initial qualifying service was no longer needed, even though the person required continuing occupa-tional therapy. AOTA submitted letters and met with CMS officials in January 2011 to discuss the legislative intent and history of the issue, as well as to provide examples of the correct applica-tion of legislative intent in ensuring that

Medicare beneficiaries qualifying for the home health benefit have full access to occupational therapy services during each episode of care.

The revised final regulation now reads:

§ 409.42 Beneficiary qualifica-tions for coverage of services. * * * * * (c) * * * (4) Occupational therapy servic-es in the current and subsequent certification periods (subsequent adjacent episodes) that meet the requirements of § 409.44(c) initially qualify for home health coverage as a dependent service as defined in § 409.45(d) if the beneficiary’s eligibility for home health services has been estab-lished by virtue of a prior need for intermittent skilled nursing care, speech-language pathology services, or physical therapy in the current or prior certification period. Subsequent to an initial covered occupational therapy service, continuing occupational therapy services which meet the requirements of § 409.44(c) are considered to be qualifying services.

AOTA is working with CMS staff as they develop examples to update Chapter 7, Section 30.4, of the Medi-care Benefit Policy Manual in order to illustrate situations where occupational therapy could become the sole qualify-ing skilled service.

Although this clarification from CMS is helpful in the final rule, AOTA contin-ues to actively pursue federal legislation to make occupational therapy an initial qualifying service in home health.

THERAPY UTILIzATIONAND CASE-MIx WEIGHTSThe final rule revised the case-mix

weights by lowering the relative weights for episodes with high therapy and increasing the weights for episodes with little or no therapy. CMS based these revisions on what it believes to be overpayments for therapy services due to the growing use of therapy assistants, as well as alleged incentives for agencies to pro-vide more therapy than is needed to maximize payments. In our comment letter, AOTA advised CMS to wait to review data from home health PPS changes implemented in April 2011. Starting in April 2011, CMS required that at defined points during a course of treatment, a qualified occupational therapist must perform the ordered therapy service. CMS also required that records be kept of whether a ther-apist or assistant provided the service. We recommended that CMS review at least 1 year of data before implement-ing additional policy changes. In its response to comments, CMS reiterated its belief that there is an inappropri-ate overpayment for therapy assistant services. CMS is gathering more data and indicated that it may implement further changes to the weights in future rulemaking. AOTA will continue to press CMS to ensure that occupa-tional therapy assistant services are properly valued.

AOTA will continue to monitor all Medicare changes related to providing occupational therapy services. Access updated information on these and other payment policy issues by going to our Web site at www.aota.org/practitioners/reimb/news. n

Jennifer Bogenrief is the manager of AOTA’s

Reimbursement and Regulatory Policy Department.

She can be reached at [email protected].

TCMS Clarifies “Continuing Qualifying Service” To Ensure Access to OT in Home Health Rule

Jennifer Bogenrief



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Home Health Documentation Guide

The Centers for Medicare & Medicaid Services (CMS) issued new Medicare home health policy directives regarding documenting patient evaluations in 42 CFR Parts 409, 418, 424, et al., published November 17, 2010, and in Transmittal 139/Change Request 7329, published February 16, 2011 which was effective on January 1, 2011, and implemented on or before April 1, 2011. Key elements affecting therapy provision are effective April 1, 2011. Measurable treatment goals must be included in the plan of care. The patient’s clinical record must identify method(s) used to assess the patient’s function. Documentation should include objective measures and successive comparison of measurements, thus enabling objective measurement of progress toward goals and/or therapy effectiveness, which will be used to determine if continued therapy is reasonable and necessary. There are a number of ways in which documentation language can provide an objective measurement of progress. Of key importance is that each agency should have a policy which defines the terms that therapists can use and apply them consistently. This document provides guidance on how to document progress based on directives issued in the past by CMS prior to implementation of LCDs. It meets the new requirements for therapy documentation and may be useful to therapists attempting to capture the goals and gains made by their patients while adhering to the new requirements. General guidelines: The evaluation must establish the physical and cognitive baseline data necessary for assessing expected rehabilitation potential, setting realistic goals, and measuring progress. The patient's functional deficits and level of assistance needed forms the basis of the OT treatment goals. Use objective tests and measurements (when possible) to establish baseline data and, if possible, the same ones for consistency in measuring change during re-evaluation.

Defining assistance 1. Min/Mod/Max assist to perform task (be sure to include not just physical assistance but assist due to safety issues, cognitive, perceptual deficits etc.) 2. Alternatively, define/describe the behavior without using min/mod/max assist.

Document the patient's functional loss and the level of assistance requiring skilled OT intervention in ability to perform Activities of Daily Living (ADL):

• Dependence Level- The individual requires skilled assistance in handling his/her ADL. These activities can include, but are not limited to, significant physical and/or cognitive functional loss, loss of previous functional gains in ability to perform ADL tasks and/or management/care of orthotic or adaptive devices.

AOTA Home Health Documentation Guide Page 2

• Reasons for Functional Limitation such as lack of awareness of sensory cues or safety hazards can include (but not be limited to):

a. Impaired attention span;

b. Impaired strength; Coordination;

c. Abnormal muscle tone;

d. Range of motion limitations;

e. Impaired body scheme;

f. Perceptual deficits;

g. Impaired balance/head control;

h. Environmental barriers

Documenting Updated Status:

Clear, concise and objective progress notes of the patient's current functional status and level of assistance required compared to previous reporting period(s) is critical. The deficits in functional ability must be clear. Occupational therapy practitioners must document functional improvements (or lack thereof) as a result of their intervention. State documentation of functional progress, whenever possible, in objective, measurable terms. The following illustrates these principles and demonstrates that significant changes may occur in one or more of these assistance levels:

a. Change in Level of Assistance.--Document assistance levels by describing the relationship between functional activities and the need for assistance. Within the assistance levels of minimum, moderate, and maximum, there are intermediate gradations of improvement based on changes in behavior and response to assistance. Document improvements at each level. Compare the current cognitive and physical level achieved to that achieved previously. While the need for cognitive assistance often is the more severe and persistent disability, the requirement of physical assistance often is the major obstacle to successful outcomes and subsequent discharge. Document the levels as follows:

� Total Assistance.--The need for 100 percent assistance by one or more persons to perform all physical activities and/or cognitive assistance to elicit a functional response to an external stimulation.

Total assistance is required if documentation indicates the patient is only able to initiate minimal voluntary motor actions and that the skill of an occupational therapist is required to develop a therapeutic program or to implement a maintenance program to prevent or to minimize deterioration.

A cognitively impaired patient requires total assistance when documentation shows external stimuli are required to elicit automatic actions such as swallowing or responding to auditory stimuli. Document what OT skills are needed to identify and apply strategies for eliciting appropriate, consistent automatic responses to external stimuli.

� Maximum Assistance.--The need for 75 percent assistance by one person to physically perform any part of a functional activity or cognitive assistance to perform gross motor actions in response to direction.


A patient requires maximum assistance if documentation shows that maximum OT physical support and proprioceptive stimulation is needed for performance of each step of an activity every time it is performed.

Document the specific need for OT proprioceptive stimulation or one-to-one demonstration by the occupational therapist due to lack of cognitive awareness of other people or objects in the environment.

� Moderate Assistance.--The need for 50 percent assistance by one person to perform physical activities or constant cognitive assistance to sustain/complete simple, repetitive activities safely.

Document that patient requires moderate assistance by indicating that moderate OT physical support and proprioceptive stimulation is needed for the patient to perform a functional activity, every time it is performed.

Records should state how a cognitively impaired patient, at this level, requires intermittent one- to-one demonstration or intermittent cuing (physical or verbal) throughout the performance of the activity. Moderate assistance is needed when documentation indicates that the therapist/caregiver needs to be in the immediate environment to assist the patient through a sequence to complete a functional activity. Document how this level of assistance requires a halt to continuing repetition of a task and to what extent assistance is needed to prevent unsafe, erratic or unpredictable actions that interfere with appropriate sequencing.

� Minimum Assistance.--The need for 25 percent assistance by one person for physical activities and/or periodic, cognitive assistance to perform functional activities safely.

A physically impaired patient requires minimum assistance if documentation indicates that activities can only be performed after physical setup by the therapist or caregiver, and if physical help is needed to initiate or sustain an activity. Document any review of alternate procedures, sequences and methods that may be required.

A cognitively impaired patient requires minimal assistance if documentation indicates the patient needs help in performing known activities to correct repeated mistakes, to check for compliance with established safety procedures, or to solve problems posed by unexpected hazards.

� Standby Assistance.--Is the need for supervision by one person for the patient to perform new activity procedures that were adapted by the therapist for safe and effective performance.

A patient requires standby assistance when errors and the need for safety precautions are not always anticipated by the patient.

� Independent Status.--No physical or cognitive assistance is required to perform functional activities.


Indicate in documentation that patients at this level are able to implement the selected courses of action, consider potential errors, and anticipate safety hazards in familiar and new situations.

b. Change in Response to Treatment Within Each Level of Assistance.

Document significant improvement in a patient's condition. Indicate any change in one or more of the following categories of patient responses within any assistance level.

• Decreased Refusals.--Document that the patient responds by refusing to attempt performance of an activity because of fear or pain. Document what activity and performance is refused, the reasons, and how the OT plan addresses them.

These responses may be due to a change in medical status or medications. If refusals continue over several days, put the therapy program on "hold" until the patient is willing to attempt performance of functional activities.

For the cognitively impaired patient, document refusal to perform that escalates into aggressive, destructive, or verbally abusive behavior if the patient is pressed by the therapist or caregiver to perform. In these cases, consider a reduction in these behaviors significant. Document the skilled OT provided to reduce the abnormal behavior.

For the psychiatrically impaired patient, refusals to participate in an activity frequently are symptoms of the diagnosis. Document the skilled OT furnished, and if the patient is contacted regularly. Describe how the patient is actively encouraged to participate.

• Increased Consistency.--Document the increase in consistency of performance of functional tasks within the same level of assistance. Document that the patient responds by inconsistently performing functional tasks from day-to-day or within a treatment session. Document the skilled OT furnished to address this problem.

• Increased Generalization.--The patient may respond by applying previously learned concepts and performance of one activity to another similar activity. Document the increased scope of activities the patient can perform, the type of activities, and the OT services rendered.

c. Example of Describing Behavior: Assessment: Bathing: requires caregiver assistance to set up shower, able to bathe upper body only. Fatigued by shower requiring 10 minute rest before dressing. Reassessment: Bathing: continues to require assistance to set up shower but is now able to bathe entire body using assistive device. Fatigue has decreased, but needs 5 minute rest before dressing.

Those statements identify where change has occurred and measure it objectively in ways that someone who never sees the patient can understand.

AOTA Guidance for Completing Functional Reassessments and Documentation in Medicare Home Health The Centers for Medicare & Medicaid Services (CMS) has issued new Medicare home health policy directives regarding documenting patient evaluations in 42 CFR Parts 409, 418, 424, et al., published November 17, 2011, and in Transmittal 139/Change Request 7329, published February 16, 2011 and effective on January 1, 2011, and implemented on or before April 1, 2011. Key elements affecting therapy provision are effective April 1, 2011. These issuances clarify roles and expectations for occupational therapists and assistants in evaluation, documentation, and progress measurement for Medicare home health. AOTA believes these clarifications are consistent with appropriate occupational therapy practice and the goals of the Medicare home health benefit. AOTA’s interpretation is that implementation of these clarifications can assist in promoting the understanding and value of occupational therapy within individual home health agencies and in the home health community. The value of occupational therapy in helping home health patients regain function, improve self-management, and reduce risk in the home can be highlighted if these new directives are implemented effectively. Occupational therapy delivers cost-effective interventions that enable home health patients to Live Life to Its Fullest.” Increased attention to evaluation, measurement and outcomes can only help to promote best occupational therapy practice and improve recognition of occupational therapy’s unique contributions in the home health setting. AOTA has developed this document to provide guidance about the requirements. This document references both CMS documents (noted by citations) and existing AOTA documents, books, and other guidance. What CMS is Emphasizing The purpose of these rules--CMS’s goal--is to increase accountability for the provision of therapy services in home health. CMS has instituted schedules for reassessments as well as reinforced documentation requirements. The purpose is to assure that in paying for home health episodes, therapy that is provided is reasonable and necessary within Medicare coverage guidelines. This means that the services are considered under accepted standards of practice to be safe and effective treatment for the client’s condition and that there is an expectation that the client’s condition will improve materially in a reasonable (and generally predictable) period of time based on the assessment of the client’s restoration potential and unique medical condition. (42 CFR § 409.44). The services must also require the skills of an occupational therapist or an occupational therapy assistant under appropriate supervision. In summary, CMS has proposed: Functional Reassessment Expectations; 30-Day Requirements: Agencies must implement strict requirements for the timing of reassessment in order to assure therapy is provided only the appropriate number of times to meet the patient’s needs and show progress in meeting goals in the plan of care. The rules include: A qualified therapist must assess the patient and measure and document progress toward functional goals at least

once every 30 days during the patient’s course of treatment. During this encounter, the therapist will also provide any other treatment needed.

Qualified therapist means an occupational therapist as specified in 42 CFR § 484.4. An occupational therapy assistant is not specified.

For patients who receive up to 13 or 19 therapy visits by a single therapy profession, the qualified therapist for that therapy will at the 13th or 19th visit perform the therapy service required, assess the patient, measure progress toward goals and document effectiveness of the therapy. In rural areas or under circumstances beyond the therapist’s control, assessment may be after the 10th visit but no later than the 13th visit, and after the 16th visit but no later than the 19th visit.

For patients receiving two or more therapies each distinct therapy service must be reassessed by performance of the discipline specific reassessment as near as possible to, but not after, the 13th or 19th therapy visit. When counting therapy visits, all billable visits by all therapists and therapy assistants are counted.

Only a qualified therapist may perform the functional reassessment to document a patient’s progress towards goals. The therapist may consider notes written by the assistant. Notes written by assistants are part of the clinical record

but need not be copied into the reassessment documentation. Clinical notes written by assistants supplement the functional reassessment process and documentation of a qualified therapist.

A therapy reassessment is not expected to be a full evaluation or comprehensive assessment. It is expected that the therapist will follow an evaluative process: collecting and interpreting the data and, if appropriate, modifying the plan of care, or discharging from occupational therapy.

Clarifications to Required Documentation for Covered Skilled Therapy Services: Documentation is the way the plan of care is described and how the above requirements for reassessment are recorded. Documentation provides the evidence on which the judgment about beginning or continuing therapy is made. Measurable treatment goals must be included in the plan of care. The patient’s clinical record must identify method(s)

used to assess the patient’s function. Documentation would include objective measures and successive comparison of measurements, thus enabling objective measurement of progress toward goals and/or therapy effectiveness, thus determining if continued therapy is reasonable and necessary.

Measurable goals should relate to accepted standards of professional practice for the condition/function which is being addressed.

Examples of acceptable objective measures: o Functional assessment individual items and summary findings from OASIS functional items or other commercially

available therapy outcomes instruments. For example, the individual OASIS item M1700 Cognitive Functioning could be used initially and subsequently to define a measure of change in a patient status regarding cognitive status.

o Functional assessment findings from specific tests and measurements validated in the professional literature; from clinically determined measurements related to the goals of the client; or measurements used as part of accepted standards of clinical practice that are appropriate for the condition/function being measured. Comparisons to prior assessment results, clinical findings or specific test results must be included in reassessments in order to document progress toward achieving measurable objectives.

How to Promote Effective Response to the Rules

In the rules, CMS is promoting what AOTA supports as effective, efficient practice based on the principles of occupational therapy. AOTA offers resources on assessments, various skills and knowledge documents and practice guidelines that can be useful in establishing measurable objectives that are consistent with accepted standards of professional practice.

In working within home health agencies to implement these rules, it is important to remember that the purpose of all assessment, measurement and documentation is to establish that the occupational therapy meets Medicare coverage guidelines; this material supports that the occupational therapy services are reasonable and necessary within Medicare coverage guidelines. This means that the services are considered under accepted standards of practice to be safe and effective treatment for the client’s condition and that there is an expectation that the client’s condition will improve materially in a reasonable (and generally predictable) period of time based on the assessment of the client’s restoration potential and unique medical condition. (42 CFR § 409.44). The services must also require the skills of an occupational therapist or an occupational therapy assistant under appropriate supervision. The rules also reference that “maintenance therapy” cannot be provided by an occupational therapy assistant; this is because under all Medicare settings and rules, maintenance therapy is not covered. Only a reevaluation of need for maintenance therapy is covered; a reevaluation may only be conducted by an occupational therapist.

How to Ensure Documentation Satisfies the Mandatory Elements: Consistent with the Occupational Therapy Practice Framework (AOTA, 2008) and Medicare requirements across all settings, measurable treatment goals must be included in the plan of care that are related to the client’s personal factors including the condition for which the home health is being provided, performance skills to be targeted, performance patterns, activity demands, context and environment, and client goals. The documentation should include explanations of the evaluation, the interventions proposed and undertaken, and the desired outcomes. The AOTA official document, Guidelines for Documentation of Occupational Therapy (AOTA, 2008), provides an outline which, if followed, ensures a comprehensive and professional format for documentation of occupational therapy services. It outlines suggested content of evaluation and screening, including development of an occupational profile and explanation of types of assessments used and results (e.g., interviews, patient record reviews, observations and standardized or nonstandardized assessments).

This official AOTA guidance reinforces the key to documenting objective, measurable function is to spell out how the patient information gathered shows the patient’s functional limitations and relates to the patient’s functional goals (occupational performance). For home health, this documentation should contain the following elements: 1. List all assessments administered (standardized and non-standardized) or OASIS items considered in relation to occupational therapy needs and the results; 2. Document how the assessments selected measure performance deficits and functional problems identified in the evaluation; 3. Document how results relate to and what they mean in terms of performance deficits and performance goals; 4. Document patient performance observed (skilled clinical observation) by therapist, including observations by the assistant and; 5. Summarize and interpret the results of assessments and observations as they relate to the person’s occupational performance (ADL, IADL, social participation, and goals of home health: to promote optimum participation, safety, self management and to remain at home), and as they pertain to continuation or revision to the goals and plan of care. How to Select Assessment Tools and Methods: Use of a standardized assessment is not required. CMS requires practitioners to include in their documentation of evaluation either the results of a specified performance measure tool or an explanation of certain factors that describe the patient’s status in relation to goals to be achieved. Clinical observation is an important assessment tool. If standardized assessments are used, therapists should consider the following factors when selecting standardized assessment instruments: • Has the assessment been validated for use in the home setting? • Has the assessment been validated for use with a population to which a given patient belongs? The AOTA Practice

Guidelines which are based on reviews and interpretations of evidence in the literature provide some assessments related to particular conditions.

• Is administration of the assessment compatible with home health service delivery (e.g., time to administer, equipment and supplies needed, control of environment, compatibility with software or documentation systems in your agency)?

• Does the instrument assess aspects of the domain of occupational therapy? The AOTA publication, Occupational Therapy Assessment Tools: An Annotated Index (2007) provides information about many tools used in occupational therapy.

• Does the instrument assess aspects of occupational performance that are relevant to the patient’s needs and goals? The Occupational Therapy Standards of Practice (AOTA, 2010) state that “An occupational therapy practitioner uses current assessments and assessment procedures and follows defined protocols of standardized assessments during the screening, evaluation, and re-evaluation process.” (p. 417). If the standardized protocol is not followed, it cannot be assumed that the results are valid. If the protocol is modified, the therapist is obligated to document the modification and the limited applicability of the findings due to the nonstandardized protocol.

Summary

These rules may cause discussion in home health agencies about the role and purpose of occupational therapy. Occupational therapy practitioners are urged to be proactive in participating in discussion about how to implement these rules and seek assistance through the AOTA resources referenced below.

Resources American Occupational Therapy Association. (2008). Guidelines for documentation of occupational therapy. American Journal of Occupational Therapy, 62(6), 684-690. doi:10.5014/ajot.62.6.684

American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62(6), 625-683. doi:10.5014/ajot.62.6.625

American Occupational Therapy Association. (2010). Occupational therapy code of ethics and ethics standards (2010). American Journal of Occupational Therapy, 64(Suppl. 6), S17-S26. doi:10.5014/ajot.2010.64S17

American Occupational Therapy Association. (2010). Scope of practice. American Journal of Occupational Therapy, 64(6 Suppl.), S70-S77. doi:10.5014/ajot.2010.64S70

American Occupational Therapy Association. (2010). Specialized knowledge and skills in mental health promotion, prevention, and intervention in occupational therapy. American Journal of Occupational Therapy, 64(6 Suppl.), S30-S43. doi:10.5014/ajot.2010.64S30

American Occupational Therapy Association. (2010). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 64(6 Suppl.), S106-S111. doi:10.5014/ajot.2010.64S106

Asher, I. E. (Ed.). (2007). Occupational therapy assessment tools: An annotated index (3rd ed.). Bethesda, MD: AOTA Press.

Forwell, S. J. (2006). Occupational therapy practice guidelines for adults with neurodegenerative diseases. Bethesda, MD: AOTA Press.

Golisz, K. (2009). Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda, MD: AOTA Press.

Sabari, J. (2008). Occupational therapy practice guidelines for adults with stroke. Bethesda, MD: AOTA Press.

Schaber, P. (2010). Occupational therapy practice guidelines for adults with Alzheimer’s disease and related disorders. Bethesda, MD: AOTA Press.

Siebert, C. (2005). Occupational therapy practice guidelines for home modifications. Bethesda, MD: AOTA Press.

Stav, W. B., Hunt, L. A., & Arbesman, M. (2006). Occupational therapy practice guidelines for driving and community mobility for older adults. Bethesda, MD: AOTA Press.



800-377-8555 TDD

www.aota.org

301-652-2682

301-652-7711 fax



OT/OTA Student Supervision & Medicare Requirements

Historically, OT and OTA students have participated in the delivery of occupational therapy services under the supervision of occupational therapy personnel in a variety of fieldwork sites. The following provides information about the way in which the Centers for Medicare & Medicaid Services (CMS) interprets how and whether the Medicare program should provide payment for services provided by students. In the article "Strategies for Creative Fieldwork Opportunities," AOTA’s Academic Affairs, Federal Affairs, Practice, and Reimbursement and Regulatory Policy staff provide guidance for occupational therapy programs, fieldwork sites, and facilities. For those settings that serve Medicare patients, it is important to be aware of both new and existing Medicare payment policies. CMS has published specific criteria relating to how and when the program will pay for services when the student participates in service delivery. When developing fieldwork plans for sites that serve Medicare patients, two issues must be considered:

1. Whether Medicare payment rules specifically allow students to participate in the delivery of services to Medicare beneficiaries, and

2. What type and level of supervision are required by the Medicare program. All relevant Medicare coverage criteria must be reviewed if reimbursement is sought for services when the student participates in service delivery. In addition, many state practice acts and regulations address occupational therapy services provided by students. You can find the regulatory board contact information on the State-by-State OT Law Database located in the Licensure section of this Web site. For details regarding AOTA’s position on level II fieldwork, please see the document Practice Advisory: Services Provided by Students in Fieldwork Level II Settings. The following chart sets out for each Medicare setting whether Medicare payment rules specifically allow or restrict coverage of services provided by students and what type and level of supervision Medicare requires to raise the services provided by students to the level of covered "skilled" occupational therapy. Practitioners should take care to ensure an appropriate level of supervision, whether or not a specific CMS rule regarding students has been issued. Medicare Coverage of Services When a Student Participates in Service Delivery

• Medicare Part A—Hospital and Inpatient Rehabilitation Type and Level of Supervision of Student Required: CMS has not issued specific rules, but in the excerpt here referencing skilled nursing facilities (SNFs), CMS mentions other inpatient settings. In the Final SNF PPS Rule for FY 2012 (76 Fed. Reg. 48510-48511), CMS stated: “We are hereby discontinuing the policy announced in the FY 2000 final rule’s preamble requiring line-of-sight supervision of therapy students in SNFs, as set forth in the FY 2012 proposed rule. Instead, effective October 1, 2011, as with other inpatient settings, each SNF/provider will determine for itself the appropriate manner of supervision of therapy students consistent with state and local laws and practice standards.” See relevant state law for further guidance on supervision for the services to be considered occupational therapy.

• Medicare Part A—SNF Type and Level of Supervision of Student Required: The minutes of therapy services provided by OT and OTA students may be recorded on the MDS as minutes of therapy received by the beneficiary. Currently and until October 1, 2011, services of OT and OTA students must be provided in the "line of sight" of the OT. OTAs can provide clinical supervision to OTA students; however, if the services are to be recorded for payment purposes, they must be performed in "line of sight" of an OT. For more details about the current student supervision guidelines in SNFs, see http://aota.org/News/AdvocacyNews/SNF-Students.aspx?FT=.pdf.

http://www.aota.org/Educate/EdRes/Fieldwork/NewPrograms/38246.aspx

http://www.aota.org/Practitioners/Licensure.aspx



http://aota.org/News/AdvocacyNews/SNF-Students.aspx?FT=.pdf


AOTA OT/OTA Student Supervision & Medicare Requirements p. 2

Change will occur effective October 1, 2011. Line-of-sight supervision is no longer required in the SNF setting (76 Fed. Reg. 48510-48511). The time the student spends with a patient will continue to be billed as if it were the supervising therapist alone providing the therapy, meaning that a therapy student’s time is not separately reimbursable. CMS is currently revising the RAI Manual for the Minimum Data Set, Version 3.0 (MDS 3.0) to incorporate the policy change. The above AOTA chart will be revised when CMS provides more specific guidance.

o Because of advocacy by AOTA, CMS has posted Recommended Guidelines by AOTA, APTA, and ASHA on its SNF PPS Web site: https://www.cms.gov/SNFPPS/02_Spotlight.asp (see Student Supervision Guidelines under “Downloads”). AOTA, APTA, and ASHA worked together to develop suggested guidelines for CMS to incorporate into its guidance on student supervision. CMS recognized the guidelines and posted them on its Web site. In the final rule, CMS stated, “we appreciate the detailed supervision guidelines that several of the trade associations have developed, which we recognize as playing a significant role in helping to define the applicable standards of practice on which providers rely in this context.”

https://www.cms.gov/SNFPPS/02_Spotlight.asp

AOTA OT/OTA Student Supervision & Medicare Requirements p. 3

• Medicare Part A—Hospice Type and Level of Supervision of Student Required: CMS has not issued specific rules. AOTA is recommending that the approach for Part A inpatient settings be followed for hospice providers. See relevant state law for further guidance on supervision for the services to be considered occupational therapy.

• Medicare Part A—Home health Type and Level of Supervision of Student Required: Regulations (§484.115) specifically cite definitions for "qualified personnel", which do not include students. However, CMS has not issued specific restrictions regarding students providing services in conjunction with a qualified OT or OTA. Services by students can be provided (as allowed by state law) as part of a home health visit, when the student is supervised by an OT or OTA in the home. AOTA is recommending that the approach for Part A inpatient settings be followed for home health agencies. See relevant state law for further guidance on supervision for the services to be considered occupational therapy.

• Medicare Part B—Private Practice, Hospital Outpatient, SNF, CORF, ORF, Rehabilitation agency, and other Part B providers including home health agencies when providing Part B services Type and Level of Supervision of Student Required: Under the Medicare Part B outpatient benefit, the services of students directly assisting a qualified practitioner (OT) are covered when the type and level of supervision requirements are met as follows: Students can participate in the delivery of services when the qualified practitioner (OT) is directing the service, making the skilled judgment, responsible for the assessment and treatment in the same room as the student, and not simultaneously treating another patient. The qualified practitioner is solely responsible and must sign all documentation. For details about current student supervision guidelines that affect Part B in SNFs in particular, see http://aota.org/News/AdvocacyNews/SNF-Students.aspx?FT=.pdf. Following is guidance to the entities that pay for Medicare benefits contained in the Medicare Benefit Policy Manual, Chapter 15 – see Section 230B:

1. General Only the services of the therapist can be billed and paid under Medicare Part B. The services

performed by a student are not reimbursed even if provided under “line of sight” supervision of

the therapist; however, the presence of the student “in the room” does not make the service

unbillable. Pay for the direct (one-to-one) patient contact services of the physician or therapist

provided to Medicare Part B patients. Group therapy services performed by a therapist or

physician may be billed when a student is also present “in the room”.

EXAMPLES: Therapists may bill and be paid for the provision of services in the following scenarios:

• The qualified practitioner is present and in the room for the entire session. The student

participates in the delivery of services when the qualified practitioner is directing the service,

making the skilled judgment, and is responsible for the assessment and treatment.

• The qualified practitioner is present in the room guiding the student in service delivery when the

therapy student and the therapy assistant student are participating in the provision of services, and

the practitioner is not engaged in treating another patient or doing other tasks at the same time.

• The qualified practitioner is responsible for the services and as such, signs all documentation. (A

student may, of course, also sign but it is not necessary since the Part B payment is for the

clinician’s service, not for the student’s services).

AOTA continues to work with a coalition of practitioner organizations to advocate for additional government support for education of allied health providers and to develop long-term solutions to the problems caused by Medicare’s limitations on reimbursement when students participate in service delivery.


https://www.cms.gov/manuals/Downloads/bp102c15.pdf

https://www.cms.gov/manuals/Downloads/bp102c15.pdf

________________________

Coding

________________________

© 2011 American Medical Association + Add-on Code

Underlined Text = Additions and Revisions for 2012

1

2012 CPT CODES FOR OCCUPATIONAL THERAPY The following CPT

© codes are frequently used by occupational therapists to report services in various settings. Additional codes,

such as Case Management, and Psychiatry codes, are sometimes accepted by private insurers for classifying and billing OT services. Not all codes are accepted by all payers, including Medicare. Limitations on use of one or more of these codes may be established by state regulation and/or payer policy. Always review state rules, the official CPT

© book, and request information

from specific insurers concerning codes, time frames, and payment policy. NOTE: Medicare requires the use of CPT© 2012

codes effective January 1, 2012. Additions and revisions for 2012 are underlined. The work of the qualified healthcare professional consists of face-to-face time with the patient (and caregiver, if applicable) delivering skilled services. For the purpose of determining the total time of a service, incremental intervals of treatment at the same visit may be accumulated.

PHYSICAL MEDICINE & REHABILITATION 97003 Occupational therapy evaluation 97004 Occupational therapy re-evaluation

MODALITIES Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.

Supervised The application of a modality that does not require direct (one-on-one) patient contact by the provider. 97010 Application of a modality to one or more areas; hot

or cold packs 97012 traction, mechanical 97014 electrical stimulation (unattended) 97016 vasopneumatic devices 97018 paraffin bath 97022 whirlpool 97024 diathermy (eg, microwave) 97026 infrared 97028 ultraviolet

Constant Attendance The application of a modality that requires direct (one-on-one) patient contact by the provider. 97032 Application of a modality to one or more areas;

electrical stimulation (manual), each 15 minutes (For transcutaneous electrical modulation pain

reprocessing (TEMPR/scrambler therapy), use 0278T)

97033 iontophoresis, each 15 minutes 97034 contrast baths, each 15 minutes 97035 ultrasound, each 15 minutes 97036 Hubbard tank, each 15 minutes 97039 Unlisted modality (specify type and time if constant

attendance)

THERAPEUTIC PROCEDURES

A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or therapist required to have direct (one-on-one) patient contact. 97110 Therapeutic procedure, one or more areas, each 15

minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113 aquatic therapy with therapeutic exercises 97116 gait training (includes stair climbing) 97124 massage, including effleurage, petrissage

and/or tapotement (stroking, compression, percussion) (Note: For myofascial release, use 97140)

97139 Unlisted therapeutic procedure (specify) 97140 Manual therapy techniques (e.g., mobilization

/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes (Do not report 97140 in conjunction with 29581-29584)

97150 Therapeutic procedure(s), group (2 or more individuals) (Group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one patient contact by the physician or therapist)

97530 Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

97535 Self 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 provider, each 15 minutes



2

97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes

97545 Work hardening/conditioning; initial 2 hours + 97546 each additional hour

ACTIVE WOUND CARE MANAGEMENT Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing. 97597 Debridement (eg, high pressure water jet

with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area: first 20 sq cm or less

+ 97598 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure

97602 Removal of devitalized tissue from wound(s), non selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

97605 Negative pressure wound therapy (e.g., Vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97606 total wound(s) surface area greater than 50 square centimeters

TESTS AND MEASUREMENTS

Requires direct one-on-one patient contact 97750 Physical performance test or measurement (e.g.,

musculoskeletal, functional capacity), with written report, each 15 minutes

97755 Assistive technology assessment (eg. 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 report, each 15 minutes

ORTHOTIC MANAGEMENT AND PROSTHETIC

MANAGEMENT

97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

(Code 97760 should not be reported with 97116 for the same extremity)

97761 Prosthetic training, upper and/or lower extremity(s), each 15 minutes

97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes

OTHER PROCEDURES 97799 Unlisted physical medicine/rehabilitation service or

procedure

SPECIAL OTORHINOLARYNGOLOGIC SERVICES 92526 Treatment of swallowing dysfunction and/or oral

function for feeding

EVALUATIVE AND THERAPEUTIC SERVICES 92605 Evaluation for prescription of non-speech-

generating augmentative and alternative communication device, face-to-face with the patient, first hour

+92618 each additional 30 minutes (List separately in addition to code for primary procedure)

92606 Therapeutic service(s) for the use of non-speech-generating device, including programming and modification

92610 Evaluation of oral and pharyngeal swallowing function

92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording

92612 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording

92614 Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording

MUSCLE AND RANGE OF MOTION TESTING 95831 Muscle testing, manual (separate procedure) with

report; extremity (excluding hand) or trunk 95832 hand, with or without comparison with normal

side 95833 total evaluation of body, excluding hands 95834 total evaluation of body, including hands 95851 Range of motion measurements and report

(separate procedure); each extremity (excluding hand) or each trunk section (spine)

95852 hand, with or without comparison with normal side 95992 Canalith repositioning procedure(s) (eg, Epley

maneuver, Semont maneuver), per day. (Not covered by Medicare, use 97112)

95999 Unlisted neurological or neuromuscular diagnostic procedure



3

CENTRAL NERVOUS SYSTEM

ASSESSMENTS/TESTS (e.g., NEURO-COGNITIVE,

MENTAL STATUS, SPEECH TESTING) 96110 Developmental screening, with interpretation and

report, per standardized instrument form

+96111 Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report

96125 Standardized cognitive performance testing (eg. Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

HEALTH AND BEHAVIOR ASSESSMENT/

INTERVENTION (Not covered under Medicare for OT-See CPT book for additional instructions for use of

these codes.) 96150 Health and behavior assessment (eg, health-

focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment

96151 re-assessment 96152 Health and behavior intervention, each 15 minutes;

face-to-face; individual 96153 group (2 or more patients) 96154 family (with the patient present) 96155 family (without the patient present)

MEDICAL TEAM CONFERENCE, DIRECT (FACE-

TO-FACE) CONTACT WITH PATIENT AND/OR

FAMILY (Not covered by Medicare) 99366 Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional 99368 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional

•••• New HCPCS Code + Special Coverage Instructions � Not Covered by Medicare ♦Revised Code HCPCS Modifiers: NU-New Equipment RR-Rental UE-Used DME

1

SELECTED 2012 HCPCS LEVEL II CODES

The following selected HCPCS Level II codes are used by occupational therapists in various settings to report fabrication and

fitting of specific upper extremity (UE) orthoses, use of specialized equipment during an occupational therapy intervention,

or to report services under specific programs or circumstances. Not all codes are accepted by all payers, including Medicare.

State regulations and/or payer policies may establish limitations on the use of one or more of these codes. Always review

state rules, the official HCPCS book, and request information from specific insurers concerning use of codes and payment

policy.

ORTHOTIC DEVICES-UPPER LIMB

Shoulder Orthosis (SO)

L3650 SO, figure of eight design abduction re-strainer,

prefabricated, includes fitting and adjustment

L3660 SO, figure of eight design abduction re-strainer,

canvas and webbing, prefabricated, includes fitting

and adjustment

L3670 SO, acromio/clavicular (canvas and webbing type),


♦L3671SO, shoulder joint design, without joints, may

include soft interface, straps, custom fabricated,

includes fitting and adjustment

••••L3674 SO, abduction positioning (airplane design), thoracic

component and support bar, with or without

nontorsion joint/turnbuckle, may include soft

interface, straps, custom fabricated, includes fitting

and adjustment

L3675 SO, vest type abduction restrainer, canvas webbing

type, or equal, prefabricated, includes fitting and

adjustment

♦+L3677 SO, shoulder joint design, without joints, may

include soft interface, straps, pre-fabricated, includes

fitting and adjustment

Elbow Orthosis (EO)

L3702 Elbow orthosis, without joints, may include soft


and adjustment

L3710 EO, elastic with metal joints, prefabricated, includes


L3720 EO, double upright with forearm/arm cuffs, free

motion, custom fabricated

L3730 EO, double upright with forearm/arm cuffs,

extension/flexion assist, custom fabricated

L3740 EO, double upright with forearm/arm cuffs,

adjustable position lock with active control, custom

fabricated

L3760 Elbow orthosis, with adjustable position locking

joint(s), prefabricated, includes fitting and

adjustments, any type

L3762 EO, rigid, without joints, includes soft interface

material, prefabricated, includes fitting and

adjustment

L3763 EWHO, rigid, without joints, may include soft


and adjustment

L3764 EWHO, includes one or more nontorsion joints,

elastic bands, turnbuckles, may include soft interface,

straps, custom fabricated, includes fitting and

adjustment

L3765 EWHO, rigid, without joints, may soft interface,


adjustment

L3766 EWHO, includes one or more nontorsion joints,



adjustment

Wrist-Hand-Finger Orthosis (WHFO)

L3806 WHFO, includes one or more nontorsion joint(s),

turnbuckles, elastic bands/springs, may include soft

interface material, straps, custom fabricated, includes


L3807 WHFO, without joint(s), prefabricated, includes

fitting and adjustments, any type

L3808 WHFO, rigid without joints, may include soft

interface material; straps, custom fabricated, includes


Additions and Extensions

♦L3891 Addition to upper extremity joint, wrist or elbow,

concentric adjustable torsion style mechanism for custom

fabricated orthotics only, each

L3900 WHFO, dynamic flexor hinge, reciprocal wrist

extension/flexion, finger flexion/extension, wrist or

finger driven, custom fabricated

L3901 WHFO, dynamic flexor hinge, reciprocal wrist

extension/flexion, finger flexion/extension, cable

driven, custom fabricated

External Power

L3904 WHFO, external powered, electric, custom fabricated


2

L3905 WHO, includes one or more nontorsion joints, elastic

bands, turnbuckles, may include soft interface, straps,

custom fabricated, includes fitting and adjustment

Other Wrist-Hand-Finger Orthoses: Custom Fitted

L3906 WHO, without joints, may include soft interface,


adjustment

L3908 WHO, wrist extension control cock-up, nonmolded,


L3912 HFO, flexion glove with elastic finger control,


L3913 HFO, without joints, may include soft interface


adjustment

L3915 WHO, includes one or more nontorsion joint(s),


straps, prefabricated, includes fitting and adjustment

L3917 Hand Orthosis, metacarpal fracture orthosis,


L3919 Hand Orthosis, without joints, may include soft


and adjustment

L3921 HFO, includes one or more nontorsion joints, elastic

bands, turnbuckles, may include soft interface, straps,

custom fabricated, includes fitting and adjustment

L3923 HFO, without joints, may include soft interface,

straps, prefabricated, includes fitting and adjustment

L3925 FO, proximal interphalangeal (PIP)/distal

interphalangeal (DIP), nontorsion joint/spring,

extension/flexion, may include soft interface

material, prefabricated, includes fitting and

adjustment

L3927 FO, proximal interphalangeal (PIP)/distal

interphalangeal (DIP), without joint/spring,

extension/flexion (e.g. static or ring type), may

include soft interface material, prefabricated,


L3929 HFO, includes one or more nontorsion joint(s),


interface material, straps, prefabricated, includes


L3931 WHFO, includes one or more nontorsion joint(s),


interface material, straps, prefabricated, includes


L3933 Finger orthosis, without joints, may include soft

interface, custom fabricated, includes fitting and

adjustment

L3935 Finger orthosis, nontorsion joint, may include soft

interface, custom fabricated, includes fitting and

adjustment

L3956Addition of joint to upper extremity orthosis, any

material; per joint

SHOULDER-ELBOW-WRIST-HAND ORTHOSIS

(SEWHO)

Abduction Positioning: Custom Fitted

L3960 SEWHO, abduction positioning, airplane design,


L3961 SEWHO, shoulder cap design, without joints, may



L3962 SEWHO, abduction positioning, Erbs palsy design,


L3967 SEWHO, abduction positioning (airplane design),

Thoracic component and support bar, without joints,

may include soft interface, straps, custom fabricated,


Additions to Mobile Arm Supports

L3971 SEWHO, shoulder cap design, includes one or more

nontorsion joints, elastic bands, turnbuckles, may




thoracic component and support bar, includes one or

more nontorsion joints, elastic bands, turnbuckles,



L3975 SEWHO, shoulder cap design, without joints, may




thoracic component and support bar, without joints,



L3977 SEWHO, shoulder cap design, includes one or more

nontorsion joints, elastic bands, turnbuckles, may




thoracic component and support bar, includes one or

more nontorsion joints, elastic bands, turnbuckles,



Fracture Orthoses

L3980 Upper extremity fracture orthosis, humeral,



3

L3982 Upper extremity fracture orthosis, radius/ulnar,


L3984 Upper extremity fracture orthosis, wrist,


L3995Addition to upper extremity orthosis, sock, fracture or

equal, each

L3999 Upper limb orthosis, not otherwise specified

Specific Types of Orthotic repairs (See L4000-L4398)

Prosthetic Procedures

Additions for the Upper Limb (See L6600-L6698)

PROCEDURES/PROFESSIONAL SERVICES

(TEMPORARY)

Note: The G codes are used to identify professional health

care procedures and services that would otherwise be

coded in CPT but for which there are no CPT codes.

Once CPT codes for these services and procedures

are assigned, the G codes are removed from this

section. G codes fall under the jurisdiction of the

payer.

G0129 Occupational therapy requiring the skills of a

qualified occupational therapist, furnished as a

component of a partial hospitalization treatment

program, per session (45 minutes or more)

For Home Health Agency and hospice Reporting

G0152 Services performed by a qualified occupational

therapist in the home health or hospice setting ,

each 15 minutes


therapist assistant in the home health or hospice

setting, each 15 minutes


therapist in the home health setting, in the

establishment or delivery of a safe and effective

occupational therapy maintenance program, each

15 minutes

Stimulation, Electrical

G0281 Electrical stimulation, (unattended), to one or more

areas, for chronic stage III and stage IV pressure

ulcers, arterial ulcers, diabetic ulcers, and venous

statsis ulcers not demonstrating measurable signs of

healing after 30 days of conventional care, as part of

a therapy plan of care

♦G0282 Electrical stimulation, (unattended), to one or more

areas, for wound care other than described in G0281

G0283 Electrical stimulation (unattended), to one or more

areas for indication(s) other than wound care, as part

of a therapy plan of care

VISION SERVICES V0000-V2999

Note: These V codes include vision-related supplies

including spectacles, lenses, contact lenses, prostheses,

intraocular lenses, and miscellaneous lenses.

V codes fall under the jurisdiction of the DME regional

carrier, unless incident to other services or otherwise noted.

Vision Aids

V2600 Hand held low vision aids and other nonspectacle

mounted aids

6 MARCH 12, 2012 • WWW.AOTA.ORG

C A p i T A l B r i e f i N g

OTA has begun a process to reex-amine the codes that are used for occupational therapy evaluation and treatment, as defined by the Physical Medicine and Reha-bilitation (PM&R) Section of the American Medical Asso-ciation (AMA) 2012 Current Procedural Terminology (CPT) system. This system is used by

practitioners and payers to define all health care procedures. For many pay-ers, including Medicare, payment for services is directly linked to the CPT code(s) billed.

AOTA believes that the existing codes do not adequately describe the present practice of occupational therapy. Many occupational therapy practitioners’ employers or payers limit which codes can be used to record occupational therapy practice, resulting in an effective limitation on scope of practice. Sometimes the choice is between two codes, neither of which adequately or correctly encompasses the intervention that is being provided.

Additionally, over the past 5 years, the Centers for Medicare & Medicaid Services (CMS) has reported steadily increasing therapy utilization and therapy code abuse. Meanwhile, CMS has conducted a number of contract projects to develop policy alternatives and, potentially, a payment system that would replace the therapy caps and ensure appropriate utilization. AOTA members and staff have par-ticipated in these multi-year contrac-tor projects to recommend Medicare policy and payment changes, including alternatives to the therapy cap. How-ever, in the 2011 Medicare Physician Fee Schedule proposed rulemaking,

CMS published three options intended to address overutilization of therapy services (for more, see www.aota.org/news/advocacynews/2011-proposed-fee-schedule-rule-cuts). One of these options includes a restructuring of the therapy codes to develop codes less based on time and with more emphasis on patient severity and the complexity of the service provided.

CMS also has become very aggres-sive in imposing administrative changes to payment policy that affect an occupational therapist’s ability to properly code, while still not solving the underlying deficiencies in the system. Specifically:n Increases in adverse therapy policy

by CMS and the continued therapy cap exception extensions have been a poor substitute for a com-prehensive approach to therapy billing and utilization management that builds on best contemporary practice.

n The existing codes may not inter-face well with recent legislation and regulation, such as the emphasis on primary care, designed to radically change which entities and under what conditions services will be paid under a future health care system.

n Use of fragmented timed codes do not present a valid picture of the occupational evaluation process and the clinical decision making continuously employed in develop-ing and implementing an effective plan of treatment.

CMS has started to target specific CPT codes, including four PM&R codes, under a number of different criteria for which they are requesting

AMA review of values. This means CMS believes that the fee schedule rates for some codes are too high. AOTA believes that it would be more rational to review the whole family of codes in relation to occupational therapy practitioners’ actual provision of therapy, rather than a code-by-code review.

In response to these growing concerns, AOTA formed a coding workgroup to consider the vulner-abilities in the present CPT coding structure; analyze the coding needs of occupational therapy today and in a new health care system; and, if seen as essential, develop potential alternative CPT codes. AOTA’s Board is overseeing the project’s goals and has appointed two Board representa-tives to participate in all aspects of the project. The group is chaired by Leslie Davidson, PhD, OTR/L, and Mary Foto, OT, CCM, FAOTA. The Board representatives are Thom Fisher, PhD, OTR, CCM, FAOTA, and Mary Ellen East, MS, COTAL, ROH.

AOTA wants to hear from you. Have you encountered problems with changes in Medicare policy or denials from payers? What types of issues (e.g., denials of codes billed together, denials of specific CPT codes, policies that limit number of billing codes) have affected your ability to practice efficiently? How do you envision a coding system that would work better for your practice? Please respond with specific suggestions for CPT coding changes to [email protected] (subject line: CPT Coding). And watch for more efforts to seek your input and participation in this critical activity. n

Judy Thomas is AOTA’s senior policy manager.

ADoes Occupational Therapy Need

Revised CPT Codes?Judy Thomas

C A p i T A l B r i e f i N g

Reimbursement and Regulatory Policy Resources Medicare Part A

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Transcript of Reimbursement and Regulatory Policy Resources Medicare Part A