Amy Schnacker, OTR/L in Nebraska.
Ron Carson wrote:
Hello All:
I have received two messages from Medicare concerning reimbursement for leisure services. I have permission to post Medicare's replies but have been asked to remove all references to the person making the replies. This is done to ensure that any replies to Medicare's message goes through the 'proper channels' and not directly to the specific representative in these messages.
I will post the entire messages as follows:
1. My 1st message to Medicare
2. Medicare's 1st response
3. My 2nd message to Medicare
4. Medicare's 2nd and final response
This will be a long e-mail, sorry!
Ron
===========> My First Message To Medicare ....
1st Message> Hello: I am an occupational therapist and owner of a 1st Message> in-home rehab company called HOPE Therapy Services. As an 1st Message> OT, I often run into clients who are having difficulty 1st Message> safely and satisfactorily performing outdoor leisure 1st Message> activities such as gardening, boating, fishing, going to 1st Message> movies, etc.
1st Message> I am looking for guidance as to whether skilled OT 1st Message> addressing such outdoor leisure activities such as the 1st Message> ones above, are reimbursable under current Medicare 1st Message> guidelines. I understand that ALL therapy services must be 1st Message> provided under a doctor's plan of care, and there must be 1st Message> evidence that such therapy is medically necessary and that 1st Message> there is documentation supporting progress towards goals.
===========> Medicare's 1st Reply ....
On4/19/2005, <address removed by request> said:
1st Reply> Dear Mr. Carson, In response to you inquiry about skilled OT 1st Reply> therapy services for outdoor leisure activities I have a few 1st Reply> references I would like to encourage you to read. Located on 1st Reply> our website www.floridamedciare.com you will find the Local 1st Reply> Coverage Determinations for Physical Therapy and 1st Reply> Occupational Therapy. Both of these policies go into great 1st Reply> detail as to what services are considered reasonable and 1st Reply> necessary under CMS (Centers for Medicare and Medicaid 1st Reply> Services) guidelines. I can tell you from a medical review 1st Reply> perspective that leisure activities such as the ones you 1st Reply> mentioned are usually not allowed as they do not fall > 1st Reply> under the category of basic ADL's. I encourage you to read 1st Reply> all the requirements on MD referrals, what is considered 1st Reply> reasonable and necessary and when designing a maintenance 1st Reply> program would be appropriate. You also will want to refer to 1st Reply> the CMS website www.cms.gov/manuals and go to the Internet 1st Reply> only Manual link (IOM) and select Pub 100-2 and then read 1st Reply> chapters 12 and 15. These chapters go into further detail on 1st Reply> covered skilled therapy services. I do not know if you are a 1st Reply> CORF or ORF facility but the medical necessity requirements 1st Reply> and documentation requirements are the same for both types 1st Reply> of facilities. Also at our website www.floridamedicare.com, 1st Reply> you can find an excellent resource for therapy services 1st Reply> which I refer all new providers to. If you select the 1st Reply> education link from the menu on the left hand side of the 1st Reply> home page and go to Education and Training Manuals and 1st Reply> select that link you will be taken to a page that lists 1st Reply> multiple education manuals. Scroll down to Specialty Manuals 1st Reply> and select Rehabilitation Services and print this manual. I 1st Reply> think after reading the references I have mentioned to you 1st Reply> many of your questions on what is considered medically 1st Reply> necessary and payable services will be answered. But as a 1st Reply> former medical reviewer, just based on your description of 1st Reply> leisure activities those services would not be payable under 1st Reply> the guidelines and policies I have referenced you to. If you 1st Reply> have any further questions please feel free to email me at 1st Reply> the below address or through [EMAIL PROTECTED] I hope 1st Reply> this information elps you.
1st Reply> Sincerely, <address/name removed by request>
=====================> My Second Message to Medicare ........
2nd Message> Hello Stephanie:
2nd Message> Thank you for the VERY quick answer!!
2nd Message> I appreciate your suggestion to review existing 2nd Message> documentation. I have already spent good amount of time 2nd Message> looking for answers and guidance to my original question. 2nd Message> Because I was unable to find adequate support in writing, 2nd Message> I contacted FCSO customer service and they suggested that 2nd Message> I send medical policy an e-mail. I've again reviewed the 2nd Message> documents that you mention but I still feel that there is 2nd Message> some 'grey area' regarding OT services for leisure 2nd Message> activity.
2nd Message> Your response mentions, 'basic ADL's' which of course, 2nd Message> leisure activities fall outside of the realm. I can not 2nd Message> find anything in writing that supports an assumption that 2nd Message> only basic ADL's but not IADL's such as fishing, hunting, 2nd Message> etc.
2nd Message> However, there is a CPT code that possibly covers IADL's: 2nd Message> 97537 Community/work reintegration training (e.g., 2nd Message> shopping, transportation, money management, avocational 2nd Message> activities and/or work environment/ modification 2nd Message> analysis, work task analysis), direct one on one contact 2nd Message> by provider, each 15 minutes.
2nd Message> If I had a doctor's order for OT Eval and Treat for a 2nd Message> patient whose diagnoses was post stroke and my signed 2nd Message> treatment plan included something like: "Patient will 2nd Message> safely and independently fish from a public pier" and this 2nd Message> treatment was billed as 97537, would this likely be 2nd Message> reimbursed?
2nd Message> Thanks,
2nd Message> Ron Carson
2nd Message> P.S. I RUN A PUBLIC LISTSERVE THAT PRIMARILY CONSISTS OF 2nd Message> OTHER OCCUPATIONAL THERAPISTS. MAY I HAVE YOUR PERMISSION 2nd Message> TO SHARE OUR COMMUNICATION WITH MEMBERS OF THIS LIST?
====================> Medicare's 2nd Reply .......
2nd Reply> Mr. Carson, I have copied the section from the OT policy 2nd Reply> regarding ADL's. I understand your feeling of there being a 2nd Reply> 'grey area' in terms of ADL's but as you see from what I 2nd Reply> have copied into this email from the OT policy that Medicare 2nd Reply> considers basic functions that allow the beneficiary the 2nd Reply> ability to feed, groom, bath etc.. medically necessary. When 2nd Reply> a beneficiary is able to perform these functions Medicare 2nd Reply> does not see the continued skills of a therapist as 2nd Reply> reasonable or necessary. You will also see that Advanced 2nd Reply> ADL's such as home maintenance, meal prep etc.. would be 2nd Reply> considered medically necessary if documented clearly and 2nd Reply> adequately according to the documentation requirements. 2nd Reply> Medicare is a limited benefit and only a very small portion 2nd Reply> of the numerous things an occupational therapist can provide 2nd Reply> to a beneficiary is covered. As for the mention of 97537 2nd Reply> covering IADL's you will see the section from the PT policy 2nd Reply> that describes the coverage for this CPT code. This is a 2nd Reply> bundled services and is not separately reimbursable and 2nd Reply> would not cover IADL's. I spoke with the manager of medical 2nd Reply> policy regarding your wanting to put our communication on 2nd Reply> your public listserve and she said although she and I both 2nd Reply> are confident with my responses to you on this subject, you 2nd Reply> can put the information obtained from our correspondence on 2nd Reply> you public listserve and identify that it came form FCSO 2nd Reply> medical policy department and that if anyone had questions 2nd Reply> or concerns you can reference them to the 2nd Reply> [EMAIL PROTECTED] email address. I ask that you please 2nd Reply> not put my name or contact information on the listserve site 2nd Reply> as any inquiries that should come from this need to go 2nd Reply> through our departments email address. I hope this 2nd Reply> information helps.
<NOTE: I have not included the OT Policy referenced above because of its length. However, I will e-mail the policy to anyone interested>
Ron
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