Ron, I disagree with the simple definition you propose of what an OT should do. Yes we should use occupation as an intervention and yes the underlying goal should be to improve occupation, however occupational therapy involves analyzing occupational dysfunction, determining its components, providing adaptations, instructing on compensations and remediating where possible. PT does not analyze occupation, nor does it use occupation as a treatment medium. The ability to "cast a fishing lure" is an extremely complex activity. To work with an impaired patient on this activity would entail treatment that cannot be described adequately by, I'll use your phrase, "teaching someone to fish."
I have seen patients and had the file paid by Medicare where I intervened to improve leisure skills. You cannot state you are teaching a person to sew, fish or whatever. You may state that you provided such and such adaptation to allow the patient to return to his/her prior occupation of _____. You can also function within the realm of OT if you use graded occupational activity to improve ROM, strength, whatever. Instead of saying you are teaching a patient to fish, use more appropriate documentation language such as the patient participated in graded (list how you are grading it) occupational tasks with whatever facilitation, instruction, hands on treatment that is associated. I don't see where that has anything to do with the way a PT would practice and I have seen intervention documented in this manner paid by multiple Medicare intermediaries. The goal would be to return to his prior ability to participate in leisure interests. In answer to your first question, Medicare pays for occupational therapy interventions which are considered reasonable and necessary. The goals and the potential to meet the same are a predetermining condition of coverage. As per most intermediaries there must be reasonable assumption that the patient's condition will improve over a predictable period of time. I'm getting frustrated with this topic. I am not advocating working as a PT, but using the technique of activity analysis, which is fundamental to OT practice. By components, I mean the individual components of the activity (a simple example would be to explore how one would teach a patient to don a shirt using backward chaining. In this approach, one would begin with a single portion of the activity, possibly graded, and then progress as mastery is achieved). The term component, as I am proposing it in this discussion, does not refer wholly to the biomechanical components. However, we must be aware that there is a biomechanical component to all occupation activities). I am simply saying that if you document that you are a tennis coach (for example), teaching someone to play tennis, you will not be paid for occupational therapy intervention. If you document using language that denotes skilled intervention, you will be paid. Jimmie -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of Ron Carson Sent: Wednesday, April 20, 2005 10:17 PM To: [email protected] 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] *** 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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