Medicare Compliance & Reimbursement

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

A pair of trade groups has joined forces and taken issue with Medicare's rules regarding reimbursement on patients that need only occupational therapy.

The American Occupational Therapy Association and the National Association for Home Care and Hospice are planning to bend the Centers for Medicare and 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.