Home Health Occupational Therapy

Title XVIII of the Social Security Act, §1814(a)(2)(C) requirement of requests and certifications

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

42 CFR §409.32 Criteria for skilled services and the need for skilled services

42 CFR §409.42 Beneficiary qualifications for coverage of services

42 CFR §409.43 Plan of care requirements

42 CFR §424.22 Requirements for home health services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §20.1.2 Determination of Coverage, §30.4 Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech-Language Pathology Services, or Has Continued Need for Occupational Therapy, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, §40.2.4 Application of the General Principles to Occupational Therapy, §40.2.4.1 Assessment, §40.2.4.2 Planning, Implementing, and Supervision of Therapeutic Programs, §40.2.4.3 Illustration of Covered Services, §50.1 Skilled Nursing, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, §40.1 Who May Sign the Certification or Recertification for Extended Care Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, §220.1.4 Requirement That Services Be Furnished on an Outpatient Basis, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services and §230.2 Practice of Occupational Therapy

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10.2 Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, §160.7 Electrical Nerve Stimulator, §160.7.1 Assessing Patients Suitability for Electrical Nerve Stimulation Therapy, §160.12 Neuromuscular Electrical Stimulator (NMES), §160.13 Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES), §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy) and §160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds and §270.6 Infrared Therapy Devices

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2 Medical Review of Home Health Services, §6.2.1 Physician Certification of Patient Eligibility for the Medicare Home Health Benefit, §6.2.1.1 Certification Requirements, §6.2.2 Physician Recertification, §6.2.2.1 Recertification Elements, §6.2.3 The Use of the Patient’s Medical Record Documentation to Support the Home Health Certification, §6.2.5 Medical Necessity of Services Provided, §6.2.6 Examples of Sufficient Documentation Incorporated Into a Physician’s Medical Record and §6.2.7 Medical Review of Home Health Demand Bills

Although rehabilitative services are provided by physical therapy (PT), speech therapy (ST) and occupational therapy (OT), this policy only addresses OT.

OT is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. OT is based on purposeful, goal directed activity (occupation). The goal of OT is to prevent, improve or restore physical and/or cognitive impairment following disease or injury.

Occupational therapists utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living (ADLs) skills, work skills and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All OT services must be performed by or under the supervision of a skilled qualified occupational therapist.

1. The treatment approach includes:

1. Evaluation
2. Basic activities of daily living (BADLs) training
3. Instrumental activities of daily living (IADLs) training
4. Muscle re-education
5. Cognitive training
6. Perceptual motor training
7. Fine motor coordination/strengthening/coordination
8. Orthotics (splinting)
9. Adaptive equipment fabrication and training
10. Environment modification recommendations/training
11. Patient/caregiver education/training
12. Transfer training
13. Functional mobility training
14. Manual therapy
15. Physical agent modalities
16. Neurodevelopment training

2. Coverage of skilled rehabilitation services is contingent upon the beneficiary's need for skilled care whether the goal of therapy includes maintenance or improvement.

3. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy may require the skilled services of a therapy professional because of a special complicating medical factor. This must be clearly evident in the medical record.

4. OT is only covered when it is rendered under a written plan of treatment established by the physician and the qualified occupational therapist and signed (including professional identity) and dated by the physician. The plan of treatment should contain, at a minimum, all diagnoses, long term treatment goals and type, amount, duration and frequency of therapy services. The physician should review the plan of treatment every 60 days.

5. The physician and/or therapist must document the patient's functional limitations in terms that are objective and measurable.

6. Rehabilitation services for vision impairment: Medicare beneficiaries who are blind or visually impaired are eligible for physician prescribed rehabilitation services on the same basis as beneficiaries with other medical conditions.

Maintenance Therapy

Coverage of skilled rehabilitation services is contingent upon a beneficiary's need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient's unique circumstance. The provision of therapy services by skilled therapy personnel does not itself make the service one that requires skilled care.

Restorative/Rehabilitative therapy

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services.

Maintenance therapy

Even if no improvement is expected, under the home health (HH) coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care.

SPECIFIC PROCEDURE AND MODALITY GUIDELINES:

Fabrication/Application of Casts, Splints and Strapping

Fabrication and application of casts, splints and strapping will be considered reasonable and necessary if used to support weak, post-surgical or ineffective joints/muscles, facilitate increased motor response, to assist in compensation in a permanent loss of motor function, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, other interventions and should be selected in the context of patients' needs, social/culture environments, BADLs and IADLs.

BODY AND UPPER EXTREMITY CASTS:

Application of long arm

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of short arm

May be indicated for the forearm, wrist and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of hand and lower forearm

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of finger cast

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

SPLINTS:

Application of long arm splint

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprain/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

Application of finger splint

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

STRAPPING:

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures, or other deformities involving soft tissue.

Strapping of low back

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder

May be indicated for any portion of the shoulder girdle complex or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist

May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated where there is involvement of the hand or fingers in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

LOWER EXTREMITY CASTS:

Application of long leg cast

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg cast

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

SPLINTS:

Applications of long leg splint

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Applications of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, contractures or other deformities involving soft tissue.

STRAPPING:

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Biofeedback Training by any Modality and Biofeedback Training, Perineal Muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry

The coverage criteria and definition of biofeedback is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence.

Evaluation of oral and pharyngeal swallowing function

The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx.

The clinical examination may include:

a) History of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder
b) Medical status including nutritional and respiratory status
c) Oral anatomy/physiology (labial control, lingual control, palatal function)
d) Pharyngeal function
e) Laryngeal function
f) Ability to follow directions, alertness
g) Efforts and interventions used to facilitate normal swallow (compensatory strategies such as chin tuck, dietary changes, etc.)
h) Identifying symptoms during attempts to swallow

The clinical examination can be divided into 2 phases:

1. The preparatory examination with no swallow
2. The initial swallow examination with actual swallow while physiology is observed

Note: Based on the findings, an instrumental exam may be recommended.

Treatment of swallowing dysfunction and/or oral function for feeding

This involves the treatment for impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal stage and esophageal phase of swallowing. Make appropriate recommendations regarding diet and compensatory techniques and instruct in direct/indirect therapies to facilitate oral motor control for feeding.

Muscle testing, manual 

Muscle testing, manual (separate procedure), extremity (excluding hand) or trunk with report

For extremity manual muscle testing, every muscle of at least 1 extremity would need to be tested with documentation of why such a thorough assessment was warranted.

Muscle testing, manual (separate procedure) with report, hand with or without comparison with normal side 

Muscle testing, manual (separate procedure) with report, total evaluation of body, excluding hands or including hands 

The measurement of muscle performance using manual muscle testing only.

Range of Motion (ROM) Measurements

This is the determination of ROM using a tape measure, ruler, electronic device or goniometer.

Standardized Cognitive Performance Testing

This testing includes neuropsychological testing (e.g., Ross Information Processing Assessment, Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Motor-Free Visual Perception Test (MVPT), Allen Cognitive Test (ACL)). This is usually done outside the OT initial evaluation/re-evaluation. 

OT Evaluation and OT Re-evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted (e.g., for a new diagnosis or when a condition is treated in a new setting). These evaluative judgments are essential to development of the plan of care (POC), including goals and the selection of interventions. The time spent in evaluation does not count as treatment time.

1. The initial examination must have components as described in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy.

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Occupational therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors and use of adaptive equipment.

3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient’s condition or functional status that was not anticipated in the POC. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.

5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days for each therapy discipline. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met or for the use of the physician or the treatment setting at which treatment will be continued.

Maintenance Program

A maintenance program is a program designed to maintain or to slow deterioration as described in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance. A maintenance program must meet criteria of CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services to be considered reasonable and necessary.  

Vasopneumatic Devices

1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.

2. Specific indications for the use of vasopneumatic devices include:

1. Reduction of edema after acute injury
2. Lymphedema
3. Education and training on the use of vasopneumatic devices for home use

Paraffin Bath

Paraffin bath, also known as hot wax treatment, is primarily used for pain to increase flexibility of soft tissue and relief in chronic joint problems of the wrists, hands, and feet.

Heat treatments of this type do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths (e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). Also, if such treatments are given prior to but as an integral part of a skilled OT procedure, the treatments would be considered part of the OT service.

Infrared Therapy

Noncoverage of Infrared Therapy Devices is described in CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.6 Infrared Therapy Devices.

Electrical Stimulation Therapy

Application of a modality to 1 or more areas, electrical stimulation, manual, each 15 minutes.

The coverage criteria and definition of Neuromuscular Electrical Stimulator (NMES) and Transcutaneous Electrical Nerve Stimulator (TENS) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10.2 Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain and Part 2, §160.7 Electrical Nerve Stimulator, §160.12 Neuromuscular Electrical Stimulator (NEMS) and §160.13 Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES).

For coverage criteria regarding TENS used for treatment of chronic low back pain (CLBP) refer to CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP).

Iontophoresis Application

1. Iontophoresis is a process in which electrically charged molecules or atoms (i.e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin.

2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body.

3. Specific indications for the use of iontophoresis application may include but are not limited to:

1. Tendonitis or calcific tendonitis
2. Bursitis
3. Adhesive capsulitis
4. Hyperhidrosis
5. Thick adhesive scar

Contrast Baths

1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.

2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

3. Specific indications for the use of contrast baths include:

1. The patient having rheumatoid arthritis or other inflammatory arthritis
2. The patient having reflex sympathetic dystrophy
3. The patient having a sprain or strain resulting from an acute injury

4. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths (e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). If such treatments were given prior to but as an integral part of a skilled OT procedure, the treatment would be considered part of the skilled OT service.

Ultrasound (US)

1. Therapeutic US is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body, US has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of US, as much as 30% more. Because of the increased extensibility US produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted ROM.

2. The application of US is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

3. Specific indications for the use of US application include:

1. The patient having tightened structures limiting joint motion that require an increase in extensibility
2. The patient having symptomatic soft tissue calcification
3. The patient having neuromas

Note: US is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES

1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

2. Use of these procedures requires that these services be rendered under the supervision of an occupational therapist.

3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any 1 or a combination of more than 1 of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

4. Services provided concurrently by an occupational therapist, physical therapist and speech therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.

5. Requires (1-on-1) direct patient contact.

Therapeutic Exercise

1. Therapeutic exercise is performed with a patient either actively, active-assisted or passively participating (e.g., isokinetic exercise, stretching, strengthening and gross and fine motor movement).

2. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

3. Therapeutic Exercise is considered reasonable and necessary if at least 1 of the following conditions is present and documented:

1. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, functional mobility deficits, balance and/or coordination deficits, abnormal posture, muscle imbalance.
2. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM or endurance as part of ADLs training, or reeducation.

4. Documentation supporting therapeutic exercise must document objective loss of joint motion, strength, coordination and /or mobility (e.g., degrees of motion, strength grades, and levels of assistance).

Neuromuscular Reeducation

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor planning, body awareness, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkrais, and Bobath).

2. Neuromuscular reeducation may be considered reasonable and necessary for impairments which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, desensitization, proprioception, hypo/hypersensitivity, hypo/hypertonicity and neglect).

Massage Therapy

1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool.

2. Massage therapy, including effleurage, pétrissage and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

1. The patient having paralyzed musculature contributing to impaired circulation
2. The patient having sensitivity of tissues to pressure
3. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles
4. The patient having abnormal adherence of tissue to surrounding tissue
5. The patient having relaxation in preparation for neuromuscular reeducation or therapeutic exercise
6. The patient having contractures and decreased ROM

Manual Therapy Techniques

1. Joint Mobilization (Peripheral or Spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

2. Soft Tissue Mobilization

This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles or stretching of shortened muscular or connective tissue.

Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

1. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk
2. Treatment being a necessary adjunct to other OT interventions

3. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy

The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size of the extremity by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.

1. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage.
2. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision.

Orthotics Fitting

1. This procedure may be considered reasonable and necessary if there is an indication for education for the application of orthotics and the functional use of the orthotic is present and documented.

2. Generally, orthotic training can be completed in 3 visits, however for modification of the orthotic due to healing of tissue, change in edema or impairment in skin integrity additional visits may be required.

3. The medical record should document the distinct treatments rendered when orthotic training for upper and lower extremity is done.

4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function but a responsible individual can be trained to apply the device.

Prosthetic Training

1. This procedure and training may be considered reasonable and necessary if there is an indication for education in the application of the prosthesis and the functional use of the prosthesis is present and documented.

2. The medical record should document the distinct goals and service rendered when prosthetic training for upper and lower extremity is done.

3. Periodic revisits beyond the third month would require documentation to support medical necessity.

Orthotic/Prosthetic Checkout

1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device.

2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown and falls).

3. These assessments may be reasonable and necessary for determining "the patient's response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap or socks and determining the patient's tolerance to any dynamic forces being applied."

Therapeutic Activities

1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques. Activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities to improve performance in a progressive manner. The activities are usually directed at a loss or impairment of mobility, strength, balance, coordination or cognition. They require the skills of occupational therapists and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written plan of treatment and be directed at a specific outcome.

2. In order for therapeutic activities to be covered the following requirements must be met:

1. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning
2. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the supervision of an occupational therapist
3. There is a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed

Cognitive Skills Development

1. This procedure is reasonable and necessary for patients who have a disease or injury in which impairment of cognitive functioning is documented. Impaired functions may include but are not limited to the ability to follow simple commands, attention to tasks, improve problem solving skills, improve memory, ability to follow numerous steps in a process, ability to complete a logical sequence task and "ability to organize parts of concepts or thoughts into a whole."

2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient and is part of the written POC.

3. Treatment techniques utilized include but are not limited to: recall of information, tabletop graded activities focusing on attentional skills (e.g., cancellation tasks, mazes), graded processes in steps which the patient must follow to complete the task and computer programs that focus on the above.

4. Development of cognitive skills must be reasonable and necessary to restore and improve functioning of the patient. Documentation must relate the training to expected functional goals that are attainable by the patient.

5. Services provided concurrently by physicians, occupational therapists and speech therapists may be covered if separate and distinct goals are documented in the written plan of treatment.

Sensory Integration

The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system, interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore, therapy should provide adaptations that allow the patient to interact with their environment that promotes well-being.

Self-Care/Home Management Training

The coverage criteria and definition of self-care/home management training is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs.

Community/Work Reintegration Training

Services that are related solely to specific employment opportunities, work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by §1862(a)(1)(A) of the Social Security Act.

Services that are covered include complex IADL’s a person must do to maintain independence in the community. These tasks involve interaction with the physical and social environment. Examples of these activities may include telephone skills, written communication, handling mail, use of money, shopping from home, emergency procedure use/skills and use of assistive technology device/adaptive equipment. This service is only covered when the skilled intervention of OT is required to achieve established goals.

Wheelchair Management Training

Wheelchair management includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit and fitting the patient/client into the chair once it is received. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall.

1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient and must be part of an active written plan of treatment directed at a specific goal.

3. The patient and/or caregiver must have the capacity to learn from instructions.

4. Typically, 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.

Physical Performance Test or Measurement

This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific written plan of treatment or to determine a patient's functional capacity.

Assistive Technology Assessment

This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient’s condition(s). Assessment determines (e.g., changes in the patient’s status since the last visit and whether the planned procedure or service should be modified). Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated.

N/A

N/A

Documentation Requirements

1. Documentation supporting medical necessity should be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request.

2. The plan of treatment written by the patient’s physician after any needed consultation with the qualified occupational therapist and signed by the physician. This must be in the patient’s medical record and made available to the A/B MAC upon request.

3. When documenting family member/caregiver training and education, the documentation should include the person(s) being trained and the effectiveness of the training and education. The training and education should be an adjunct to the active therapy with the patient.

4. Outcome and Assessment Information Set (OASIS) data should support the medical necessity of the services documented in the medical records. For therapy services, the OASIS should be filled out completely. An updated and completed OASIS for the billing period should be on file in the patient’s medical records and be made available to the A/B MAC upon request.

5. The HH clinical note must contain documentation elements as outlined in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy.

6. Maintenance Program

• In maintenance programs the documentation must reflect that skilled therapy is necessary to achieve the goals of the planned maintenance program.

7. Documentation must support coverage.

8. Under a restorative program the therapist should adjust the exercise program when needed to meet the beneficiary's needs in response to regular re-evaluation.

9. OT services would be covered at a duration, frequency, and intensity such that the skills of a therapist are required to perform the services with that duration, frequency, and intensity. The patient's needs for therapy must be documented.

Plan of Treatment

Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with the qualified licensed therapist and signed (including professional identity) and dated by the physician after an appropriate assessment (evaluation) of the condition (illness or injury) is completed. The plan of treatment must be completed before active therapy begins. The plan of treatment must be signed by the referring or attending physician prior to billing the service to Medicare. The written plan of treatment may not be altered by an occupational therapist. *Electronic signatures are acceptable if the proper documentation is submitted to the A/B MAC. However, stamped dates are not allowed.

1. The written POC must contain the following elements:

• Diagnosis being treated and the specific problems identified that are to be addressed
• Treatment techniques/modalities or procedures being used for specific problem to attain the stated goals
• Specific functional goals for therapy in objective measurable terms (patient/caregiver maybe included or taken into consideration)
• Frequency and duration of services
• Rehabilitation potential - therapist/physician's expectation of the patient's ability to meet the goals at initiation of treatment (patient and, when appropriate, caregiver goals may be incorporated)

Treatment Note/Clinical/Progress Notes 

A treatment note should be written for each visit describing the services performed as well as the patient's progress, and any treatment variations from the POC with an explanation for them. Progress must be documented using specific and objective descriptions (e.g., ROM in degrees, distance that can be walked, validated scales of functional independence). Vague descriptions such as "doing well" or "continue treatment plan," will not be considered sufficient documentation of the treatment session to justify that the services rendered were reasonable and necessary. 

The treatment/clinical/progress notes should be written using objective measurements and functional accomplishments. Use statements which demonstrate the patient's response to the therapy such as:

1. "Able to perform exercises as prescribed for 15 reps"
2. "Able to safely transfer from bed to toilet with standby assistance"
3. "Can now abduct shoulder 120 degrees"
4. "Able to don a pull over shirt with minimal assistance"

Avoid terms such as:

1. "Doing well"
2. "Improving"
3. "Less pain"
4. "Increased ROM"
5. "Increased strength"
6. "Tolerated treatment well"
7. "Continue with POC"

Evaluation/Re-evaluations

The physician and/or qualified licensed therapist's evaluation/re-evaluation assess the area for which OT treatment is being planned. It must be completed prior to beginning therapy. Evaluations must contain the following information:

1. Reason for referral

2. Diagnosis/condition being treated

3. Past level of function (be specific)

4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress

5. Current level of function

6. Objective measurements such as strength, ROM, pain, ADL level, or edema

7. Treatment techniques/modalities selected for treating current illness or injury

8. Limitations which may influence the length of treatment

9. Short and/or long-term goals stated in objective measurable terms

10. Frequency and duration of therapy

11. Re-assessments must be performed at least every 30 days by a qualified licensed therapist. The 30-day clock begins with the first therapy’s visit/assessment/measurement/documentation (of the OT)

Certification/Re-certification

In order for HH patients to be eligible to receive services under the Medicare HH benefit the following must be documented for certification/re-certification:

1. The certifying physician must document that he or she had a face-to-face encounter with the patient.

2. Certifications and re-certifications by the physician, must be on file and available to the A/B MAC when the request for payment is forwarded.

3. The patient is under a physician care.

4. The referring/attending physician establishes or reviews the plan of treatment and makes the necessary certifications and he/she must sign and date all certifications/re-certifications. Certifications are required upon initiation of therapy and at least every 60 days thereafter for HH. If the requirements for certification are not met then claims for subsequent episodes of care, which require a recertification, will not be covered - even if the requirements for recertifications are met.

5. Skilled need services must be medically necessary and documentation of the skilled need should be in the patient's medical records.

6. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time, or the need to establish a safe and effective maintenance program.

7. Homebound status with documentation of confinement to home in medical records.

Utilization Guidelines

Whether the therapy is rehabilitative/restorative or maintenance should be indicated with reference to ADLs/IADLs and current ability.

Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. New Engl J Med.1990;322(17):1207-1214.

Ben-Yishay Y, Diller L. Cognitive remediation in traumatic brain injury: Update and issues. Arch of Phys Med and Rehabil. 1993;74(2):204-213.

Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.

Lawton MP. The functional assessment of elderly people. J Am Geriatr Soc. 1971;19(6):465-481.

Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. Clin Geriatr Med. 2003;19(1):19-33.

Occupational therapy practice guidelines for adults with alzheimer’s disease and related neurocognitive disorders. The AOTA Practice Guidelines Series; AOTA. (2001)

Occupational therapy practice guidelines for adults with neurodegenerative diseases. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for adults with rheumatoid arthritis. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for adults with spinal cord injury. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for adults with stroke. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for chronic pain. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for adults with traumatic brain injury. The AOTA Practice Guidelines Series; AOTA. (1999)

Occupational therapy practice guidelines for tendon injuries. The AOTA Practice Guidelines Series; AOTA. (1999)

The Institute of Medicine’s Committee on a National Agenda for Prevention of Disabilities. Executive Summary in Disability in America: Toward a national agenda for prevention. National Academy Press, Washington, D.C., 1991.

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