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Demonstration of Our Skills in Documentation Is Our Responsibility to Secure Reimbursement

Recent Medicare Part B Reimbursement Set-Back
As you have likely heard, as of July 1, 2008 CMS is implementing the therapy cap without an exceptions process and counting services against the cap looking back to January 1, 2008.


Congress may pass Medicare legislation which includes an extension of the therapy exceptions process after they return from recess the week of July 7th. However, it is unclear whether or not the exceptions process will be made retroactive from January 1, 2008 through June 30, 2008.


AOTA is continuing to urge Congress to address these issues through legislation immediately upon their return from July 4 recess on Monday July 7, 2008. Please see the AOTA website to learn more and for information on how you can help at http://www.aota.org. Additionally, information can be obtained on http://www.apta.org and http://www.asha.org.


Documentation Is a Responsibility We Must Take Seriously
If you work in an environment that bills Medicare Part B, your ability to properly serve beneficiaries with Alzheimer's disease is greatly impacted by the therapy cap exception process, as the cap extension allows the time needed to achieve optimum results. While I am gravely disappointed in the decision by Congress I must put some of the ownership for this outcome on us. Please let me explain.


No matter what source you bill (Med A, Med B, or other sources) documentation and coding is a critical element for securing reimbursement for each claim and for demonstrating our effectiveness as clinicians and a discipline. Unfortunately, for many reasons, I have not seen much documentation that paints a clear picture to support our complex claim or that identifies our expertise and effectiveness as clinicians and professionals.


Serving persons with ADRD is extremely complex, requiring a high degree of assessment and treatment skill. We must be able to analyze and understand the many underlying functional impairments and their relationships while being able to sort through and address the many comorbid complications such as behavior problems, physical deficits, psychiatric complications, etc.


Our documentation must describe:

  • Our client's cognitive status and the relationship of the client's cognitive level to function, safety, the plan of treatment, and the discharge plan.
  • Cognitive strengths that can be utilized to promote Best Ability to Function (BATF) and cognitive deficits that must be managed.
  • How we use our advanced skills such as activity analysis to create the “just-right challenge” and environmental adaptations to facilitate use of remaining abilities and to maximize safety.
  • The communication techniques used to facilitate best expressive and receptive skills and ultimately BATF, maximum safety, and QOL.
  • How we analyzed and developed strategies to reduce behavior complications such as fear and anxiety, depressed mood, and resistance to care in order to promote BATF and maximum safety.
  • How we have identified areas of high risk and developed a plan to “prevent or minimize” these complications that might otherwise occur due to dementia and other comorbid issues.
  • How we have trained others to use the techniques and implement the maintenance program we developed to promote the client's BATF.
  • The reasons we may need longer treatment sessions and extended durations such as the client's slow processing time/latency of response, the preparatory work to gain trust and agreement every session, and the time spent identifying problems introduced by the care partner or environment that could cause “excess disability,” a decline in function or safety, and negative behavior responses.
  • The complications that often arise from ADRD necessitating therapy intervention such as falls, weight loss, behavior issues, difficulty performing self-care, etc.

I believe that many things contribute to the lack of quality therapy documentation including:

  • The fact that we are not reimbursed for our time spent documenting.
  • Use of forms that aren't designed to discuss and describe cognition and other aspects related to Alzheimer's care to the extent necessary.
  • The therapists' lack of skill and understanding in “functional cognition” and the underlying cause and relationship of cognition to function, safety, the ability to learn, and communication.

I am hopeful that Congress will extend the exception process after their recess, but I am cautiously optimistic. Costs are definitely rising related to serving persons with ADRD and Medicare is at risk for going bankrupt in the future. Therefore, we must step to the plate with good documentation in order to secure our future and to secure the right to the adequate amount of therapy for Medicare beneficiaries with ADRD. We must document and highlight how our services are not simply adding costs but instead saving money through facilitation of higher function, good health, and better overall well-being.