In recent years, we have become increasingly aware of the pervasive effects of Alzheimer's and related dementias on a person's entire day and sense of well-being. Occupation across the lifespan gives meaning, pleasure, comfort, and purpose. Engagement in a task that we can do, are interested in, and satisfied with is at the core of feeling worth. Dementia Care Specialists has provided therapists with the necessary training and skill building to assist in the process of identification of "ill-being," excess disability, and the critical importance of a life story not being forgotten. Dispersing activities in a day to elicit a sense of worth and comfort is the task of skilled therapeutic intervention with progressive degenerative diseases. How do we do that?

While this article tends to be more related to a SNF/ALF environment, billing Medicare remains the same for regulations. Medicare A for Home Health, utilizing the OASIS needs to be a separate article. Medicare B (or Managed Medicare insurances) in any setting requires the same "justification" of skilled intervention.

Treating a person with an Alzheimer's or related dementia diagnosis under Medicare reimbursement still presents us with the same parameters of the regulations. For therapy services to be covered, they must be "reasonable and necessary."


"The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist. There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function." Medicare Benefit Policy Manual, Pub 100-02, Sect 220-230


A therapist's screening skill is the primary key. Therapists must have the professional "eyes" (skills and analysis) to "see through" a sign or symptom and look for other manifestations of the inability in the rest of the day.

Cognitive impairment intervention addressing functional areas such as grooming, dressing, and eating is more commonly addressed. However, the ability to address lack of participation in other types of activities such as purposeful activities, as an isolated intervention, becomes more challenging.

As mentioned in April's article on the Med B cap exception process, the primary medical diagnosis is important. 331.0 (Alzheimer's Disease) is an automatic exception, 290.0—290.4 (Dementias) are complexities and thus need an additional medical and/or treatment intervention code. The presence of a dementia diagnosis can have many manifestations and thus complicates therapy intervention. The "complexity" of this skilled, covered service is the therapist's ability to determine the cognitive level, train caregivers, and adapt environment/approaches. In this complexity of service is also taking that life story and bringing whatever we can to this new environment with this cognitive ability level.

When intervening with a person who has cognitive/memory impairment related to Alzheimer's and/or dementia, participation in all meaningful activities should always be included in the total treatment Plan of Care (POC) in addition to typical ADL and mobility activities such as dressing, grooming, eating, gait, posture, etc.

For the purpose of increasing participation in activities, it is essential to know the life story of the person. A skilled service is evaluating and developing an implementation plan (Maintenance Program, FMP) to make connections to memories and thoughts that they haven't been able to get a hold of for a very long time. Procedural memory, interests, and person-centered treatment lead us to enhance intervention and results. Understanding the directives for patient care helps us in the wording of our documentation and supporting skilled intervention.

Addressing Activity as an Occupation
In a SNF, the MDS 2.0 (Section N) records the "Activity Pursuit Patterns" of each resident. Below quotes are from CMS's RAI Version 2.0 Manual.

  • N1:   Check all periods when resident was awake all or most of the time. (Morning, Afternoon, Evening)

Intent: "The resident who is awake most of the time could be encouraged to become more mentally, physically, and/or socially involved in activities. The resident who naps a lot may be bored or depressed and could possibly benefit from greater activity involvement."

  • N2:   Average time involved in activities. (>2/3 of time, 1/3 to 2/3 of time, <1/3 of time, none)

Intent: "To determine the proportion of available time that the resident was actually involved in activity pursuits as an indication of his or her overall activity involvement pattern. This time refers to free time when the resident was awake and was not involved in receiving nursing care, treatments, or engaged in ADL activities and could have been involved in activity pursuits and Therapeutic Recreation."

  • N3:   Preferred Activity Setting:
    • Own room
    • Activity room
    • Inside NH/off unit
    • Outside facility
    • None of above

Intent: "To determine activity circumstances/settings that the resident prefers, including circumstances in which the resident is at ease."

  • N4:   General Activity Preferences (adapted to resident's current abilities)

Intent: "Determine which activities of those listed the resident would prefer to participate in (independently or with others). Choice should not be limited by whether or not the activity is currently available to the resident, or whether the resident currently engages in the activity or not."

  • Cards/games   
  • Crafts/arts
  • Exercise/sports
  • Music
  • Reading/writing
  • Spiritual/religious activities
  • Trips/shopping
  • Walking/wheeling outdoors
  • Watching TV
  • Gardening or plants
  • Talking or conversing
  • Helping others
  • None of above

Interesting note on the directives for the process on how to determine N4:
"Consult with the resident, the resident's family, activities staff members, and nurse assistants. Explain to the resident that you are interested in hearing about what he or she likes to do or would be interested in trying. Remind the resident that a discussion of his or her likes and dislikes should not be limited by perception of current abilities or disabilities. Explain that many activity pursuits are adaptable to the resident's capabilities. For example, if a resident says that he used to love to read and misses it now that he is unable to see small print, explain about the availability of taped books or large print editions.

*For residents with dementia or aphasia, ask family members about resident's former interests. A former love of music can be incorporated into the care plan (e.g., bedside audiotapes, sing-a-longs). Also observe the resident in current activities. If the resident appears content during an activity (e.g., smiling, clapping during a music program) check the item on the form. . . . If none are preferred . . . explore other possible sources of information."

  • N5:   Prefers change in daily routine.

Intent: "To determine if the resident has an interest in pursuing activities not offered at the facility (or on the nursing unit), or not made available to the resident. This includes situations in which an activity is provided but the resident would like to have other choices in carrying out the activity (e.g., the resident would like to watch the news on TV rather than the game shows and soap operas preferred by the majority of residents; or the resident would like a Methodist service rather than the Baptist service provided for the majority of residents). Residents who resist attendance/involvement in activities offered at the facility are also included in this category in order to determine possible reasons for their lack of involvement.

Review how the resident spends the day. Ask the resident if there are things he or she would enjoy doing (or used to enjoy doing) that are not currently available or, if available, are not 'right' for him or her in their current format. If resident is unable to answer, ask the same question of a close family member, friend, activity professional, or nurse assistant. Would the resident prefer slight or major changes in daily routines, or is everything OK?"

"Or is everything OK?"
That's where "skilled intervention" comes in. Admissions, activities, and medical chart may indicate who this person is and was. How does a building elicit the smiling, interests, or even hand clapping to demonstrate that this resident is involved in more than 2/3 of the time (after ADL and treatments)? How does a building engage persons in an occupation that "fits" them, their long-term memory, and avoid the wandering or behavioral symptoms that indicate "ill-being"? That is where a therapist needs to examine who they are/were and how they are interacting now in this new environment.

How do we proceed with a safe, recognizable, occupation-based, and calming environment for our residents who are "not OK"?

After establishing a cognitive level and mode
This is the primary resource to document skilled intervention and complexities. Establishing best ability and comparing that to daily interactions is the documentation you need to support intervention. Then use the CMS wording (Pub 100-02 and MDS Manual) in your documentation and to help you focus your treatments and outcomes.

In your evaluation you should include the person's present level of involvement in activities, descriptions of affect in activities, and objective descriptions of affect/behaviors throughout the day.

Example: "Patient #1 is brought to Activity department 1x/day via wheelchair. Eyes closed, head down for 90% of event, no active participation. Patient is present in front of TV during afternoon hours, will converse with staff when approached, and calls out loud for help during shift change each day. Family reports patient was a seamstress, enjoyed fine clothing and window shopping."

"Patient #2 ambulates to Activity department 1x/day with min. assist, remains in the activity for 5 min., then leaves. Patient wanders into others' rooms, stares out windows, and states to staff that she needs to leave 6 to 8 times/day. Records indicate patient was an avid gardener and was raised in a rural area."

Your evaluation must also include a description of the patient's best ability level according to the ACL level and mode.

Sample Goals:
The long-term goal can be all encompassing according to the description of best ability level.
Example:  Patient #1 will engage in an activity designed for personal interests for 2 hours with setup and cueing (per Allen Level) 5x/week.

Short-term goals:

  1. Patient will remain alert with eyes open and head up for 50% of activity event. (Therapist implementation = train activity department and adapt events to enable patient to participate each day. Billable service requires patient to be present and demonstrate interaction.)
  2. Patient will actively engage in personal interest items presented 1-2 hours/day. (Therapist implementation = train staff and develop/adapt personal interest items to be presented to patient during TV hours and shift change. Billable service requires patient to be present.)
  3. Patient will reduce calling out for help from daily to intermittent <2x/wk.

Example: Patient #2 will remain attentive to personal interests for 1-2 hours throughout the day with supervision.

Short-term goals:

  1. Patient will actively engage in gardening activities in the activity room daily for 20 min. with supervision. (Therapy implementation = develop and train activity staff on patient gardening abilities and interests.)
  2. Patient will be trained to water plants throughout the facility with setup and supervision.
  3. Patient will handle watering container in a safe manner.

Example Treatment ICD-9 Coding
Each patient is specific with needs, levels, and interests. As mentioned, it is best to include participation in activities as part of the total intervention for other manifestations identified with dressing, grooming, and eating.

Treatment ICD-9 codes can include the physical components you may need to address that were a by-product of the cognitive impairment:

728.2 Muscle wasting, disuse atrophy (Can Patient #2 hold a watering can? How much water? What size can?) (Does Patient #1 need to have stretching, positioning, exercises in order to hold head up?)

780.02 Transient alteration of awareness (While this may normally apply to persons with Alzheimer's and dementias, it may also be due to environmental change and the lack of occupation.)

780.93 Memory loss, not specified elsewhere (Many patients identified with cognitive impairment, may not have the "official" diagnosis in the medical chart. With official diagnosis of Alzheimer's or dementia, this is a given and should not be used for treatment.)

781.3 Lack of coordination (This is not a given with the diagnoses addressed. Lack of coordination can be a result of unfamiliar circumstances and tasks.)

783.21 Abnormal weight loss

783.3 Feeding difficulties

783.7 Failure to thrive, adult (The above 3 are all related to conditions in which a person is not content in their environment and thus support skilled intervention.)

780.99 Decreased functional activity (Last resort, if fine and gross motor is perfect and there are no other symptoms except memory and active engagement in a task of interest, documentation would have to support how use of this treatment intervention code can reduce assistance by caregivers, increase safety, and improve the quality of life for the patient.)

799.3 Debility, unspecified (What could this possibly mean? Some Intermediaries for Medicare will recognize this ICD-9 code in place of 780.99 This becomes your specific area recommendation, with the same cautions as above.)

Sample CPT coding for treatments
Again each patient is specific in regards to treatment interventions. The CPT codes indicate the skilled interventions you are using to achieve your results. Many therapists use the same coding to describe treatments. Consider other descriptors of the skilled necessity of your service.

97110 Therapeutic Exercise—incorporates passive/active ROM, stretching, flexibility to restore muscle groups.


97112 Neuromuscular training of movement, balance—incorporates kinesthetic sense of movement, muscle memory, proprioception, "where am I in space." This is a common treatment for persons who do not turn corners well or are unaware of corridors.

97140 Manual therapy—incorporates any hands-on interventions to correct postural concerns. Upright posture is not simply positioning. Restore the trunk and muscle disuse first as much as possible before the "body molding."

97150 Group—incorporates your time observing and assisting in activities.

97530 Therapeutic activities—this is a multi-parameter code that incorporates movement sense, sensory, and tasks all at the same time.

97532 Cognitive skills development—this includes, attention, memory, problem solving, and includes compensatory training.

97533 Sensory integration—intended to report sensory integrative techniques, which are performed to enhance sensory processing and promote adaptive responses to environmental demands. When a deficit in processing occurs, input from one of the sensory systems decreases an individual's ability to make adaptive sensory motor and behavioral responses to environmental demands.

97535 Self-care/home management training—incorporates specialized assistive techniques for patients with cognitive, physical, sensory, or perceptual deficits to assist patients in ADLs or their caregivers.

97537 Community/work reintegration—incorporates shopping, transportation, money management, avocational activities, with environmental modifications. For patients who may be returning to a previous living environment.

Final comment
Let yourself be creative and fun. Discover the moment in which the person you want to help out of his or her environmental and psychosocial sad cycle opens eyes, is engaged, and demonstrates a "sense of well-being." If others could do it, they would have.

Your skills, insights, and training are the missing pieces that are the "quality" they all deserve in life.