I believe it's the underlying barriers to the function / occupation and how we as OT's approach (and then document) them that is the key to "medical necessity" here.
How about analyzing the role and medical necessity of Occupational Therapy working with the fisherman and the gardener vs. the role of the Therapeutic Recreation Specialist? Medicare pays for OT, but doesn't pay for Therapeutic Recreation. Why - what's the clarifying distinction that makes our service "payable?" How about Physical Therapy ? Is there a medically necessary role for them in the treatment of these cases ? Breaking down what we do into its smallest component parts is what enables OT's to uniquely analyze function in such a way as to explain the medical necessity of our treatment to overcome the performance barriers. "Chunk it down" and then document it - medical necessity will become apparent. Also, what part does the physician's prescription have in determining medical necessity ? If a physician writes a prescription for "Gardening / fishing 2 x weekly x 30 days," will Medicare cover it ? Of course not. But, if the rx is "OT 2x weekly x 30 days" and I choose gardening or fishing as the task / activity that will deliver the therapeutic exercise (97110), therapeutic activity (97530) or self / home / equipment management (97535) or community re-integration (97537), then, I believe it will be covered. I will explain in my documentation how barriers to performance components of the are being addressed through the tasks /activities that I ( an OT - an expert in task analysis and human performance components) have chosen to deliver my treatment modalities. I hope this helps. Carol P. ----- Original Message ----- From: "Ron Carson" <[EMAIL PROTECTED]> To: <[email protected]> Sent: Wednesday, April 20, 2005 8:17 PM Subject: [OTlist] Discussion on OT Goals vs.Treatment {long message} > The discussion about Medicare reimbursement for leisure services has > been long. I learned from the information that was provided on the list > and by Medicare and appreciate all the input! > > However, I admit to being confused because I was under the impression > that originally there was discussion about leisure training not being > reimbursable but then at the end, the discussion was about 'appropriate > documentation' of underlying components. So, I went back through all the > messages, pertaining to this topic and extracted relevant comments. The > results of this process can be found at the end of this message. Before > continuing on, it may be helpful to read those comments. > > In going back through the comments, I'm left with a couple of really > important discussion points. > > 1. What exactly does insurance pay for; treatment or goals? I don't > really know anymore. Of course, CPT codes are for treatment and that is > how therapy is billed and paid. But the CPT codes are only used to > document procedures used to obtain goals. So, it seems that Medicare > pays for both; procedures that are used to meet medically necessary > goals. Will someone clarify my confusion? > > 2. What is it that OT (and PT for that matter) are really doing. Jimmie > suggests that Medicare will pay for OT to address underlying issues > which prevent someone from going fishing (or whatever IADL). However, > what then becomes the goal; fishing or the underlying components needed > to go fishing? If the goal is underlying components, then how is it that > we can be sure that the patient can actually go fishing. And to do so, > may require an extended period of treatment, which then of course become > non-payable. And, isn't that what PT claims to do; address underlying > issues so that a person can engage in some ADL/IADL? Isn't OT supposed > to be about occupation and that occupation is our speciality and if > fishing is someone's occupation then aren't we supposed to address > fishing and not from just an underlying components perspective but from > a whole perspective? > > It seems to me that if OT addresses the underlying components required > for someone to do occupation, then there is very little difference in > this type of approach compared to what OT has traditionally be doing for > the past 20 years! If I write a goal like: "Client will actively flex > left wrist to 90 degrees to hold fishing rod", isn't the real goal the > wrist flexion and not the fishing? Now, if fishing is the goal and is > stated: "Client will demonstrate ability to safely and independently > cast a fishing lure", then obviously casting is the goal BUT we know > that such goals are not payable. > > I think that I have more to write, but I am overwhelmed and confused! > > Ron > > ################### EXTRACTED MESSAGES FOLLOW #################### > > Shellie> I told her we could work on her balance while making a meal, > Shellie> etc but she wasn't interested in that. She wants to get out > Shellie> and plant flowers. > > Sheelie> I really struggled with this. PT could do strengthening and > Sheelie> balance training. I didn't think an insurance company would > Sheelie> cover for IADL'S without having more significant problems. > > ======================================================================= > > Ron> I don't think there's any insurance company that will pay for > Ron> someone to learn to plant flowers! > > ======================================================================= > > Shellie> I asked her what she would like to do better and she kept > Shellie> returning to the flowers and gardening. > > ======================================================================= > > Jimmie> Her desire to, "wants to get out and plant flowers" sounds like > Jimmie> an occupational goal to me. > > ======================================================================= > > Ron> My point is that insurance will not pay for someone to learn > Ron> gardening. > > ======================================================================= > > Jimmie> Again, I disagree! > > ====================================================================== > > Jimmie> It would all depend on how you document. If you say I'm going > Jimmie> to teach her how to garden, sure you will be denied. On the > Jimmie> other hand, if you analyze the component processes required for > Jimmie> the patient to engage safely in her prior occupation of > Jimmie> gardening, and you document such, you should be reimbursed for > Jimmie> this training as you would for any other OT treatment. > > ======================================================================= > > Ron> ALL interventions for which Medicare pays must be medically > Ron> necessary. IMO, gardening is not medically necessary. I don't see > Ron> anything that you quote that clearly indicates Medicare will pay > Ron> for gardening, hunting, fishing, rock climbing, tree scaling, > Ron> windsurfing, 4-wheeling, skydiving, etc. > > ======================================================================= > > Terrianne> You're right -no one would pay you to teach her to plant > Terrianne> flowers, BUT if you can clearly document how her client > Terrianne> factors, context, etc affect performance skills, then > Terrianne> describe how the task demands (versus naming the actual > Terrianne> activity) of the therapeutic occupation are remediating the > Terrianne> performance issues, you're set. > > ====================================================================== > > Jimmie> Neither do you see anything that states they will not pay for > Jimmie> it. It depends on how you document! They will not pay for you > Jimmie> to take the patient on a hunting trip, but they will pay for > Jimmie> you to assess and provide interventions to improve the > Jimmie> components of the ability to hunt. > > ======================================================================= > > Ron> Like I said, there is a line where treatment becomes non-medically > Ron> necessary. Neither I nor you now where that line exists! Not even > Ron> Medicare knows the exact location of that line - it's a case by > Ron> case situation. > > ====================================================================== > > > > > > > > > > > -- > Unsubscribe? > [EMAIL PROTECTED] > > Change options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/[email protected] > > Help? > [EMAIL PROTECTED] > -- Unsubscribe? [EMAIL PROTECTED] Change options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected] Help? [EMAIL PROTECTED]
