Like I said, there is a line where treatment becomes non-medically necessary. Neither I nor you now where that line exists! Not even Medicare knows the exact location of that line - it's a case by case situation.
I called Medicare Customer Service to try and get an answer. The rep could not give specific guidance and suggest that I send a message to Medical Policy. However, she did say that if all other criteria are met, there is a chance that leisure skills may be reimbursed. But, then we discovered that the Florida Intermediary does not allow the leisure CPT procedure code (97537) to be billed as a separate charge. What does Medicare pay for goals or procedures; or is it procedures to achieve goals? I honestly don't even know why I am arguing this point because for years I believed that Medicare would pay for leisure. Somewhere, something has made me change my mind, but I don't know what that something is? Strange! Ron ===========> Original Message Follows .... On4/15/2005, Jimmie Arceneaux, <[EMAIL PROTECTED]> said: > Neither do you see anything that states they will not pay for it. > It depends on how you document! They will not pay for you to take the > patient on a hunting trip, but they will pay for you to assess and > provide interventions to improve the components of the ability to > hunt. Are you telling me that if you had a CVA patient that wanted to > fish, and the problem was he couldn't grasp the rod while reeling with > the non affected limb, you wouldn't address this? Are you telling me > that Medicare wouldn't allow you to address this patient's grasp > and/or fabricate adaptive equipment to improve his ability to complete > bimanual tasks? > Jimmie > -----Original Message----- > From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] > Behalf Of Ron Carson > Sent: Friday, April 15, 2005 10:43 AM > To: Jimmie Arceneaux > Subject: Re[4]: [OTlist] Home Health Question > Hey Jimmie: > I do not mean this to be sarcastic, but there is an imaginary line where > treatment becomes non-medically necessary. There are literally thousands > of things that we can do as therapists that are outside the realm of > medically necessity. For example, if I had a stroke and couldn't go > fishing, should Medicare pay an OT to teach me how to go get in my car, > drive to the boat ramp, unload my boat, go fishing, clean fish. And what > about going hunting, should Medicare pay for an OT to teach me how to > hunt. This can go on and on, forever. > ALL interventions for which Medicare pays must be medically necessary. > IMO, gardening is not medically necessary. I don't see anything that you > quote that clearly indicates Medicare will pay for gardening, hunting, > fishing, rock climbing, tree scaling, windsurfing, 4-wheeling, > skydiving, etc. > Maybe I'm wrong Jimmie, I don't know! > ===========> Original Message Follows .... > On4/15/2005, Jimmie Arceneaux, <[EMAIL PROTECTED]> said: >> Again, I disagree! >> Case and point from the Palmetto LMRP for home health OT: >> "Occupational Therapists utilize clinical history, observation, >> interview, standardized testing and assessment of activities of daily >> living skills, work skills, and leisure skills to characterize >> individuals impairments, functional limitations and to design an >> individualized plan of treatments to assist in improving or restoring >> function." In the same LMRP, under treatment approaches it includes, >> "instrumental activities of daily living (IADL)training. The LMRP for >> Home Health Psychiatric care states "selecting and teaching task >> oriented therapeutic activities designed to restore and increase >> cognitive abilities and functional participation....", and "planning, >> implementing and supervising therapeutic tasks and activities designed >> to restore sensory-integrative function..." From the outpatient OT >> LMRP, "Occupational therapy is based on purposeful, goal directed >> activity (occupation)." The definition of the CPT code 97530 is >> therapeutic activities, direct (one-on-one) patient contact by the >> provider (use of dynamic activities to improve functional >> performance.) The definition of CPT codes 97537 Community/Work >> reintegration training is (eg shopping, transportation, money >> management, avocational activities...." >> Jimmie >> -----Original Message----- >> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] >> Behalf Of Ron Carson >> Sent: Thursday, April 14, 2005 8:24 PM >> To: Joan Riches >> Subject: Re[2]: [OTlist] Home Health Question >> Yeah, I have no problem with that! I'm a big time vegetable gardener. >> My point is that insurance will not pay for someone to learn gardening. >> Don't plants have testosterone??? >> R ===========>>> Original Message Follows .... >> On4/14/2005, Joan Riches, <[EMAIL PROTECTED]> said: >>> Ron - like Suzanne I'm not in the US but in my book gardening is an >>> IADL as well as a meaningful occupation for many people - particularly >>> post menopausal women who benefit immensely from the plant estrogens >>> although they may not realise that is a big reason why they love their >>> gardens so. >>> Joan Riches >> -- >> Unsubscribe? >> [EMAIL PROTECTED] >> Change options? >> www.otnow.com/mailman/options/otlist_otnow.com >> Archive? >> www.mail-archive.com/[email protected] >> Help? >> [EMAIL PROTECTED] >> *** NOTICE--The attached communication contains privileged and >> confidential information. If you are not the intended recipient, DO >> NOT read, copy, or disseminate this communication. 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