Authored by: Mary Gennerman, OTR/L

Many notable philosophers and authors have addressed the topic of change. A few of those are:

“There is nothing permanent except change” Heraclites

 

“The world hates change, yet it is the thing that has brought progress” Charles Kettering

 

“Just because everything is different doesn’t mean anything has changed” Irene Peter

 

Changes
This past June, the Medicare Benefit Policy Manual incorporated previous changes and established new changes regarding therapy. At the beginning of October the ICD-9CM classifications included new codes appropriate for therapy use. In January, 2006, all therapists whose billing was through a Fiscal Intermediary will now be subject to the Correct Coding Initiative (CCI) edits and modifiers. Some of these changes are described in this article.

The Alzheimer’s Association declared a multi year project on Dementias and in 2005 has 18% of their grants exploring best practices in care and strategies to support diagnosed individuals, their caregivers and family members.

The American Automobile Association (AAA) has released a low cost/free interactive safe driving program which includes cognitive elements. They also sponsor a paper test, ‘Drivers 55 Plus’ to indicate crash risk.

Therapeutic intervention scrutiny for Medicare beneficiaries has increased, recognizing the relevance and importance of rehabilitation professionals. “Doesn’t mean that anything has changed”. The client centered focus, the passion for maximizing independence, the collaboration among professionals … has been better defined. The regulations that require increased accuracy in reporting therapeutic interventions move therapists to a higher level of clinical reasoning, professionalism and recognition.

Medicare Benefit Policy Manual—CMS has clarified language, certs & recerts.
Publication 100-02 is the Medicare Benefit Policy Manual. Chapter 15, Section 220.1 and following, defines Coverage and Payment for Physical Therapy, Occupational Therapy and Speech-Language Pathology Services.            (Web links to sites follow this update). {Therapy services in government regulations are always referred to as ‘Outpatient’, even when they are provided in a SNF}

Section 220.1.2A has clarifications on ‘Establishing the Plan of Care.

The plan of care must be established by a physician/NPP, Physical, Occupational, or Speech Therapist.

"The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider’s or supplier’s staff when they make a written record of that person’s oral orders before treatment is begun."

 

"The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits. It is appropriate that treatment begins when a plan is established."

 

"Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same qualified professional who establishes the plan and that plan is established and signed by close of business on the next day by the same qualified professional."

 

Section 220.1.3 Certification and Recertification of Need for Treatment and Therapy Plans of Care defines the time limits in which the physician/NPP have to certify/recertify the established therapy plan of care. The reference to ‘interval of treatment’ is 30 calendar days. A totally verbal order must have some signature within 14 days. Certification of the plan of care must be within 30 days.

"Timely certification of the first interval of treatment is met when physician/NPP certification of the plan for the first interval of treatment is documented, by signature or verbal order, and dated before the end of the interval. If the order to certify is verbal, it must be followed within 14 days by a signature to be timely."

 

"Payment and coverage conditions require that the plan must be reviewed, dated and signed by a physician/NPP every 30 days…When therapy services are continued for longer than 1 month, the physician/NPP who is responsible for the patient’s care at that time should review and certify the plan for each interval of therapy. It is not required that the same physician/NPP order, certify and/or recertify the plans."

Section 220.2D in this Chapter defines Maintenance Programs as a covered service.

“The specialized knowledge and judgment of a qualified therapist would be required, and services are covered, to design or establish the plan, assure patient safety, train the patient, family members and/or unskilled personnel and make infrequent but periodic reevaluations of the plan.”

 

The maintenance program statement above has not been altered however Chapter 15 has consolidated all therapy information into one place for a better flow.

Specialized design of a maintenance program for persons with a dementia or Alzheimer’s diagnosis and the training is a covered service. Carrying out the maintenance program is not a covered service.

New ICD-9CM Codes:
As of October 1, 2005, many new “V” codes were added. “V” codes must be used in conjunction with a Primary Medical Diagnosis. “V” codes provide a more detailed picture of conditions.

Of special note for professionals treating persons with dementias are:

V15.88 History of fall, at risk for falling

V49.84 Bed confinement status

Addition of one of these codes to a primary medical diagnosis for a person with dementia provides a fuller explanation on the claim as to why therapy is involved. Treatment diagnoses are in addition to the medical.

Example: A patient is admitted to a SNF after 5 days in the hospital. She lived in an ALF which provided 2 meals, but no other services. She had her own kitchenette apartment. She did not attend meals for 2 days and was found by ALF staff lying on the floor in her apartment. Admitting diagnosis: 290.0 Dementia, unspecified and 276.5 Dehydration.

Adding V15.88 (Risk for falling) provides additional information on the Medicare claim to justify intensive OT intervention. A therapist may choose treatment diagnoses of 729.9, Imbalance of posture, 783.3, Feeding difficulties, or 783.7, Failure to thrive. The ‘risk for falling’ code supports CPT interventions of static or dynamic exercise (97110, 97530), cognitive and self care management (97532, 97535), and possible enhanced sensory processing (97533).

V49.84, Bed confinement status, coupled with a dementia diagnosis, supports interventions for seating, positioning to attend activities and/or sensory integrative techniques for adaptive responses to environment demands (caregivers, roommates, family).

Correct Coding Initiative (CCI) Edits to Apply to ALL Therapy Providers
As of January 1, 2006 all settings for therapy must use the CCI guidelines. Previously, the Edits were not imposed on Skilled Nursing Facilities or Home Health Agencies. Therapists must understand the complete description of CPT codes and know what other codes may be ‘components’ of that code. Modifiers can be utilized to separate distinct services that might otherwise be in conflict.

Each provider setting should have inservices for the therapy and billing departments in regard to this new implementation. Therapists need to be aware first, in order to avoid a billing office making determinations about your treatments. References for the CCI edits follow at the end of this update.

Example: Dynamic therapeutic activities (97530) is a comprehensive code that includes cognitive skills (97532), sensory processing techniques (97533), self care management (97535) as components. Use of the component CPT codes would have to be a distinct, separate time and have a modifier added (59). The Plan of Care and short term goals need to be specifically defined and implemented in sessions apart from each other if the therapist chooses to report 97530.  Otherwise any dynamic activity tasks should be reported under the other codes.

American Automobile Association (AAA)
AAA has introduced an interactive CD “Roadwise Review: A Tool to Help Seniors Drive Safely Longer”. It is available at full-service AAA branch offices for $3.00 for AAA members and $5.00 for non-members.

This tool does require some knowledge of using a computer mouse. It includes cognitive components and early detection of risk.

The AAA Foundation for Traffic Safety also provides free copies of ‘Drivers 55 Plus’ which is either internet or paper based. It gives custom suggestions for improvement.

Initial evaluations for driving are a covered Medicare service. Interventions are not covered unless the deficits relate to other ADL functions.

Resources
Medicare Benefit Policy Manual
http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf

ICD-9CM manuals can be purchased from the American Medical Association
http://www.ama-assn.org/

Or free link that indicates the new codes can be found at:
http://www.icd9coding1.com/flashcode/home.jsp

The Correct Coding Initiative notification will link to the actual edits. This can be found:
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0545.pdf

American Automobile Associations
http://www.aaa.com        
You may need to enter in your zip code, then in the search box type in “Roadwise Review”   Choose the first link that comes up.

AAA Foundation for Traffic Safety - link to ‘Drivers 55 Plus’
http://www.seniordrivers.org/research/driver55.pdf

Download our free eBook, Communication Tips for Serving Individuals With Dementia.

Already an Instructor or Site Member? Login to access your free resource.