Home Health & Hospice Week

If CMS makes OT a qualifying service, scheduling could get a whole lot easier.

How many times has this happened in your home health agency: A patient needs occupational therapy only, but a physical therapist or speech-language pathologist must visit the patient first, just so Medicare will pay for the OT's services? This common scenario could become a thing of the past, two trade groups hope.
 
The American Occupational Therapy Association and the National Association for Home Care & Hospice are planning to bend the Centers for Medicare & Medicaid Services' ear on a long-standing difference of opinion regarding OT as a qualifying service for home health.
 
The basics: CMS and its contractors maintain that for a home health patient to receive OT services, the OT must initiate those services before the patient receives the final qualifying PT, SLP or skilled nursing visit. "NAHC and AOTA believe that this policy is based on an incorrect interpretation of Medicare home health statutory language," NAHC explains.
 
CMS identifies the following as qualifying services, so long as they are certified as skilled services by a physician: nursing services, physical therapy services, speech-language pathology services, and "continuing occupational therapy services ... if the beneficiary's eligibility for home health services has been established by virtue of a prior need for intermittent skilled nursing care, speech-language pathology services, or physical therapy in the current or prior certification period" (42 CFR 409.42(c)).
 
Translation: CMS reads this regulation to mean that unless a patient receives OT services before discontinuing one of the other qualifying services, the OT is a "dependent service" and therefore is not covered.
 
AOTA and NAHC argue that this home health coverage regulation is based on a misrepresentation of an awkwardly written Medicare statute. The statute at Section 1814(a)(2)(C) of the Social Security Act says, "a homebound individual qualifies for home health when the individual needs or needed skilled nursing care ... on an intermittent basis or physical or speech therapy, or in the case of an individual who has been furnished home health services based on such a need and who no longer has such a need for such care or therapy, continues or continued to need occupational therapy."
 
The associations believe that when CMS wrote the coverage regulation, it inappropriately substituted "continuing occupational therapy" for the statutory language's "continues to need occupational therapy." "OT may be initiated and considered to be the qualifying service if the need for OT is identified and OT services are ordered prior to the patient being discharged for the qualifying service," NAHC says.
 
CMS' regulation twists the legislative language, says NAHC's Mary St. Pierre, "and in doing so creates an artificial barrier to occupational therapy."
 
"We think this is something CMS will be able to resolve within the existing regulatory structure," says Leslie Stein Lloyd, regulatory council for AOTA.
 
The change could eliminate an often unnecessary layer of service. "Many times all the patient needs is the services of an OT," but the PT must go in and assess things that don't need to be assessed just to get OT through the door, notes Francine Wheelock, director of program development in rehabilitation services for HealthReach Home Care & Hospice in Gardiner, ME.

OTs Admitting Patients Remains an Issue

If AOTA and NAHC convince CMS to stop considering OT to be a dependent service, OTs will no longer have to visit a patient before a PT, SLP or nurse's final visit. This change also could bolster the argument that OTs should be able to admit patients to home health, Lloyd says.
 
Several state OT associations now are working to convince CMS to allow OTs to complete the initial assessment to admit a patient, says Cindy Krafft, director of rehab services for OSF Home Care in Peoria, IL.

This change "is long overdue," Krafft notes. "PTs and OTs are equally educated, and to say that OTs are not qualified to assess the patient is really inappropriate," adds Wheelock.