Adult Rehab Guide

Medicare Coverage and Occupational Therapy’s Role in Adult Rehabilitation

Clarice Grote, MS, OTR/L

© 2023, Amplify OT

Self-published

CGrote@amplifyot.com

www.amplifyot.com

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, stored in a database and/or published in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher. This is a single-use document so it may not be shared with others without written permission of the publisher.

Disclaimer: This information is not medical, business, or legal advice. Please note, this guide is not comprehensive and it is always important to seek out more information to understand the nuances of each reimbursement setting and the role of OT. By nature, policy can change at any time, so this information may at some point be inaccurate or incomplete due to a change. If you have any concerns, please contact us at amplifyot.com/contact-us or cgrote@amplifyot.com.

Dedication

This guide is dedicated to all the lives we touch.

“Everyone tells me what my disease will do to my body, but no one has told me how it will impact my life.”

– Former patient with ALS

Preface

Hi there! I’m Clarice Grote, an occupational therapist, healthcare policy enthusiast, advocate, and founder of Amplify OT. I created Amplify OT in October 2020 to increase resources about Medicare policy, billing, and reimbursement that speak directly to occupational therapy.

When I was a new grad, I was often told, “Medicare doesn’t cover that,” when I tried to advocate for my patients and my plan of care. I lost money as a result, and my patients lost access to the care they needed. Little did I know that Medicare did cover my services. But… because I didn’t know what language to use or what resources to turn to, I just took what my boss said at face value.

By learning about policy, you won’t need to risk your license on the advice of social media or supervisors. Understanding policy is essential not only for ensuring we comply with both state and federal laws, but it is also necessary for accurate reimbursement, patient access, attaining leadership positions, and of course, advocating for OT’s unique value.

I genuinely love policy, and I think you will too😉 At Amplify OT, we make policy easy so you can do what you do best – change lives. Through my guest lectures, courses, and resources, I have helped hundreds of clinicians and students go from guessing to confident!

You deserve to understand your role as an OT practitioner and how reimbursement impacts you, your job, and your patients. As an occupational therapist, I understand that working with patients and being in the clinic can feel intimidating and exhausting. It’s hard to determine what is up from down, especially regarding reimbursement. That’s why I hope to make things easier by saving you some of that precious free time.

So, please enjoy this Adult Rehab Guide, and I hope it provides you with more clarity on OT’s unique value in each adult setting.

The world needs OT, and it requires you! So, get ready to use this knowledge to speak up and speak often and advocate for your role.

Clarice Grote, MS, OTR/L

Table of Contents

Common Insurance Terms

Insurance impacts our plan of care in many different ways. That’s why it’s important to understand Medicare and general health insurance terms. Each plan and what it covers will be different regarding private insurance. Some insurance plans only cover a certain number of visits each year or episode of care. Others may pay per visit versus paying based on the length of the visit.

Coinsurance

Coinsurance is the percentage of costs a patient pays after they have met their deductible. So, if you have a visit that costs $100 and your coinsurance is 20% after your deductible, you will owe $20 for that visit. Medicare patients have a 20% coinsurance for all Part B services. Since coinsurance is a percentage, the amount the patient owes varies with each service/visit.

Copay

Copays are payments made by the patient in addition to the payment by the insurer. It is typically a fixed amount for each visit regardless of if the patient has met their deductible. Depending on the frequency of visits, copays may significantly increase a patient’s cost as they may also owe a coinsurance or partial payment on top of their copay.

Out of Pocket

Out of pocket is another way of saying cash-based service. Typically, this is how individuals pay for care if they either don’t have insurance, insurance doesn’t cover a service, or they choose not to use insurance coverage.

Out of Network

Out-of-Network means that a clinician does not have a contract with that specific health insurance plan as a provider. Seeing out-of-network providers are often more expensive than seeing in-network providers. Some plans, like HMOs, don’t cover services provided by out-of-network providers.

Covered vs Approved

Some services are listed as covered benefits under an insurance plan’s policy manual. However, some services require certain conditions or pre-approval before the insurance approves to pay for the service on behalf of the patient. This process can be frustrating for some patients as they feel like they are getting one story from the insurer and a different story from providers. It is important to have open communication with patients during this process.

Types of Health Insurance

Medicare

Medicare is the only publicly available federal health insurance program in the US. It is available to adults over the age of 65, ALS, people with disabilities, and those with End-Stage Renal Disease requiring dialysis or a transplant. Congress and the Centers for Medicare & Medicaid Services (CMS) set Medicare policy. CMS is a branch of Health and Human Services (HHS).

Medicaid

Medicaid is federal and state-run insurance for children or individuals and low-income families. Generally, individuals who are under the Federal Poverty Level (FPL) are eligible unless states have chosen to expand this coverage. Medicaid is not required to cover therapy services and may cover some services Medicare typically does not such as nursing homes, long-term care, and personal aid services. Some states have expanded Medicaid under the Affordable care Act meaning they may cover almost all adults at up to 138% of the FPL.

Private or Commercial Insurance

Private or commercial insurance refers to any health insurance plan provided by a private entity vs. the federal or state government. Common private health insurance plans are BlueCross BlueShield, Aetna, UnitedHealthcare, Humana, etc. The cost and coverage of these plans vary widely. Plans that are eligible to be traded on the Marketplace must meet specific coverage guidelines such as the Essential Health Benefits.

Health Maintenance Organizations (HMOs)

HMOs are insurance plans that aim to reduce spending through a tight network of providers and pre-approval processes. Typically, to see a specialist, the patient will need to see their primary care provider first to receive a referral vs. being able to access the specialist directly. Generally, an HMO will not cover any out-of-network providers unless it is an emergency. So, beneficiaries trade options in care providers for lower costs in premiums.

Preferred Provider Organizations (PPOs)

PPOs are a type of insurance plan that typically has both in-network and out-of-network providers, but patients may have a higher premium than HMOs. Seeing an in-network provider is typically free or less expensive than receiving care from an out-of-network provider. Additionally, beneficiaries can see a specialist without a referral. Generally, there is better coverage for individuals who may seek care outside of their state/area or who need care while traveling under a PPO plan.

Medicare

Original Medicare/”Hospital” Part A

Medicare Part A is also known as Traditional or Original Medicare. Part A covers inpatient care in hospitals, critical access hospitals, inpatient rehab, hospice, home health, and skilled nursing facilities (SNF). Many individuals are eligible for premium-free Part A benefits. Part A may have multiple deductibles or coinsurances per year depending on benefit periods. All traditional Medicare patients have Medicare Part A. Cost of Medicare Part A premiums are based on how long an individual or their spouse paid Medicare taxes.

Part B

Medicare Part B covers medically necessary ‘outpatient’ services. Coverage includes tests and services and preventative care. Part B also covers ambulances, durable medical equipment (DME), mental health services, and some outpatient drugs. For therapy, it covers outpatient therapy or hospital observation stays. Part B covers 80% of these costs leaving patients with a 20% coinsurance for all Part B services. Medicare Part B is optional coverage with a monthly premium adjusted based on income. Part B also has a small annual deductible.

Part D

D is for Drugs. Medicare Part D covers prescription drug treatments based on a “formulary” with drug tiers. These plans are managed by private insurers.

Part C/Medicare Advantage

Medicare Advantage (MA) is an alternative to Original Medicare. These plans are instead managed by private insurance companies. MA plans are also referred to as Medicare replacement plans, or Medicare Part C. MA plans must cover Part A and Part B services at a minimum. Some also cover Part D services. Many individuals are attracted to these plans because they may be less expensive up front and may cover additional services such as aides, dental care, etc. Over 50% of Medicare eligible beneficiaries are on a Medicare Advantage plan.

What Medicare Doesn’t Cover

Medicare typically doesn’t cover long-term care, dental, eye exams, dentures, cosmetic procedures, hearing aids, routine foot care, etc. Medicare also doesn’t cover wellness or preventative therapy services.

Medicare Supplemental Plans/Medigap

Medicare Supplemental plans help cover copays, coinsurance, and deductibles and are sold by private companies. They are identified by letters F, G, K, L, M, & N.

Reimbursement Types

Understanding the reimbursement type and structure helps practitioners understand employer goals and expected types of services in each setting. Suppose the reimbursement is volume-based, like outpatient services, employers may expect the clinician to provide a larger quantity or volume of services. If the reimbursement system is value-based, the employer may expect the clinician to provide services of high value while reducing volume.

Fee-for-Service Models

Fee-for-service models are volume-based. Volume-based models incentivize practitioners to provide a larger quantity and the most expensive services vs. only providing services with the most value to the patient. Fee-for-service is like going to the grocery store, where you pay a specific price per item. So the store is incentivized to sell you as many items as possible. This model has led to higher utilization of services and duplicative services. The Centers for Medicare & Medicaid Services (CMS) has set a goal to phase out all fee-for-service plans.

Value = (Quality of Care + Services Provided) / Cost of Care

Bundled Payment Models

Bundled payment models are value-based reimbursement. They are the most common reimbursement model in adult rehab settings. Bundled payments in their purest form involve one lump sum for all necessary care in an episode without adjustments, such as the Comprehensive Joint Replacement Program (CJR). While most therapy reimbursement structures are not true bundled payment models, they operate like a bundled payment model in that facilities receive an adjusted lump sum payment based on client factors to pay for all necessary services in that episode of care, as opposed to paying a separate fee for each service. The goal is only to provide care that is necessary for optimal outcomes.

Capitated Payment Models

Capitated payment models are value-based reimbursement models. Insurance companies issue per-patient (per capita) payments each month to providers to cover the cost of all care needed by the patient. Occupational therapy practitioners rarely deal directly with capitated payment models. However, this model does influence the amount of therapy provided, especially when working with HMOs, PPOs, or Medicare Advantage plans.

Quality Measures

Quality measures are utilized in all settings and with most payers to evaluate and report on the quality of care. The type and quantity of quality measures vary, but they nonetheless play an important role. If a company emphasizes fall reduction, readmission reduction, infection control, etc., it is most likely because of reported quality outcomes. Quality measure outcomes are publicly reported on all Medicare claims and can be viewed for each facility by going to medicare.gov/care-compare.

Quality measures are developed in numerous ways, but one of the primary developers is the National Quality Forum (NQF) and Battelle. NQF and Battelle have numerous committees that work on creating quality measures for different settings and diagnostic groups. Battelle replaced NQF as the contracted quality measure parter for CMS in 2023.

Medicare’s Quality Reporting Program (QRP)

The Centers for Medicare & Medicaid Services (CMS) utilizes quality measures to track patient outcomes and adjust payments, like in value-based purchasing programs or the Merit-Based Incentive Payment System (MIPS). CMS describes quality measures as,

“…tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.”

CMS collects this data through claims, patient surveys, and providers’ reports. Each setting has a Quality Reporting Program through Medicare, and these measures are publicly published at cms.gov. Therapy practitioners can have an important impact on improving quality outcomes.

Potentially Preventable Episodes

CMS has a group of quality measures that appear in multiple settings that are considered potentially preventable or avoidable. These episodes are generally high-cost and are considered preventable if high-quality care is provided. Generally speaking, these measures include:

  • Falls
  • Potentially Avoidable Hospital Readmissions
  • Catheter-Associated Urinary Tract Infections (CAUTI)
  • Hospital-Associated Infections (C-Diff, MRSA, etc.)
  • Skin Integrity

Acute Care

Admission Criteria

In acute care, the acuity of illness is of a nature that the patient medically requires 24-hour oversight by nurses and physicians. The average length of stay is 5.5 days in the US, with some as short as 24-48 hours. Some patients are admitted through the emergency department or ED, while others may be a “direct admit,” meaning they are admitted from the doctor’s office before arriving at the hospital.

Reimbursement

Inpatient Stay: Typically require >2 midnights – billed through Medicare Part A under the Inpatient Prospective Payment System (IPPS) as a bundled payment called a Diagnosis Related Group (DRG) based on the patient’s diagnosis. Patients are responsible for a deductible per benefit period. Clinicians may co-treat as needed by the patient.

Observation Stay: <2 midnights – billed through Medicare Part B as fee-for-service. Patients may be responsible for a 20% coinsurance. The purpose is to identify if the patient requires additional care or can be released. Observation stays are commonly seen with joint replacements or operations requiring minimal recovery. If clinicians co-treat, they must split their minutes.

Therapy can optimize reimbursement and quality outcomes in hospitals through safe discharge planning, decreasing falls, and shortened length of stays.

OT’s Role and Interventions

Plan of Care: Typically only a few visits before discharge.

Length of Visit: Averages around 15 to 45 minutes

Focus of Visit: Stabilize medical status and provide discharge recommendations through a thorough occupational profile assessment. Aim to prevent deterioration while in hospital and improve function and cognition.

Interventions: Typically activities of daily living (ADLs) and education. Rarely able to engage in Instrumental activities of daily living (IADLS).

  • Caregiver Training
  • Delirium Prevention/Treatment
  • ADLs
  • Energy Conservation
  • Equipment Recommendations
  • Bed and Room Mobility
  • Functional Transfers
  • Chronic Disease Management

Type of Diagnoses

Diagnoses vary depending on the type of hospital. Common diagnoses include cardiovascular disease, pulmonary diseases, joint replacements, orthopedic traumas, neurologic traumas, post-surgery, multi-trauma, substance abuse, cancer, amputation, dementia, failure to thrive, etc.

Long-Term Care Hospitals (LTCH)

Admission Criteria

In long-term care hospitals (LTCH), the acuity of illness must be of a severity that 24-hour oversight by nurses and physicians is required; however, the patient must be stable enough to transfer out of a traditional hospital. The average length of stay for the facility must be over 25 days per the Centers for Medicare & Medicaid Services guidelines. Patients are assessed using the Long Term Care Hospital Continuity Assessment Record and Evaluation (CARE) data set (LCDS) at admission, which includes Section GG.

Reimbursement

Medicare Part A – All patients have inpatient status due to the prolonged length of stay. LTCHs are paid under the LTCH prospective payment system (LTCH PPS) using the MS-LTC-DRG or Medicare severity long-term care diagnosis related group. The DRGs used in LTCH are the same groups used in acute under the Inpatient Prospective Payment System. There are outlier payments for patients with a shorter stay or a higher cost than usual. Clinicians may still utilize CPT® codes to report the type of care provided even though reimbursement by Medicare is typically not based on billed units. Clinicians may co-treat as needed by the patient.

OT’s Role and Interventions

Plan of Care: Will see patients numerous times before discharge.

Length of Visit: Varies based on patient tolerance and abilities.

Focus of Visit: Discharge to home or post-acute, positioning, improving function, cognition, and endurance.

Interventions: Typically activities of daily living and education. Rarely able to engage in instrumental activities of daily living.

  • Caregiver Training
  • Delirium Prevention/Treatment
  • ADLs
  • Energy Conservation
  • Wheelchair Evaluations
  • Equipment Recommendations
  • Bed and Room Mobility
  • Functional Transfers
  • Orthotics
  • Chronic Disease Management

Type of Diagnoses

Patients in this setting require long-term monitoring, such as individuals requiring ventilators or high-flow oxygen, long-term antibiotics, severely debilitated individuals, and patients with complex wounds. Diagnoses include post-intensive care syndrome, neurological disorders, kidney failure, post-COVID, infectious disease, complications post-surgery, or multiple chronic conditions.

Inpatient Rehab Facilities (IRF)

Admission Criteria

The average length of stay in Inpatient Rehab Facilities (IRF) is thirteen days. Patients must require and be able to tolerate three hours of therapy at least five days a week or 15 hours of therapy total per week and must need at least two therapy disciplines once admitted. They must also require a certain amount of medical oversight. Additionally, IRFs must comply with the 60% rule, as explained below. The Inpatient Rehab Facility Patient Assessment Instrument (IRF-PAI) must be completed at admission and discharge, which includes Section GG.

Reimbursement

Medicare Part A – Although similar to a bundled payment based on diagnosis, a fee-for-service component requires three hours of therapy, five days a week, or 15 hours of therapy per week between at least two therapy disciplines. The IRF Prospective Payment System (IRF PPS) pays for care based on the assigned reimbursement impairment code (RIC), which is then further differentiated based on the case-mix group. The case-mix group includes the patient’s age, physical and cognitive function, and primary diagnosis or impairment. Section GG is used to determine functional impairments for payment.

OT’s Role and Interventions

Plan of Care: See patients for 1 – 1.5 hours a day 5 days a week on average.

Length of Visit: Typically 30 minutes to one hour twice a day.

Focus of Visit: Discharge to home, activities of daily living, instrumental activities of daily living, and patient-stated goals.

Interventions:

  • Caregiver Training
  • ADLs and IADLs
  • Energy Conservation
  • Bed and Room Mobility
  • Vision
  • Equipment Recommendations
  • Neuro-reeducation
  • Functional Transfers
  • Orthotics
  • Chronic Disease Management

Typical Diagnoses

The Compliance Threshold requires that 60% of the IRF patient population have a primary diagnosis or comorbidity of at least one of 13 conditions, including:

  • Stroke
  • Spinal Cord Injury
  • Congenital Deformity
  • Amputation
  • Major Multiple Trauma
  • Hip Fracture
  • Brain Injury
  • Certain neurological conditions (e.g., Parkinson’s, MS)
  • Burns
  • Three Arthritis Conditions for which outpatient therapy has failed
  • Hip or Knee replacement when bilateral, BMI >50, or patient is >85 years old.

Skilled Nursing Facility (SNF)

Admission Criteria

The average length of stay in Skilled Nursing Facilities (SNF) is 20-38 days. If the patient has Medicare, they must have a 3-midnight inpatient (not observation) stay in a hospital to qualify for SNF coverage. The patient must require daily skilled care and have a hospital-related medical condition. Therapy services and nursing services can meet the criteria of daily skilled care.

Reimbursement

Medicare Part A – The Patient-Driven Payment Model (PDPM) is a variable per-diem payment which functions similarly to a bundled payment model. The Medicare Data Set (MDS) with Section GG is used to determine patient factors for reimbursement for case mix groups.

Medicare Part A covers 20 days at 100% and 80 days at 80% for a total of 100 covered SNF days per benefit period. SNF benefits refresh if the patient does not receive skilled services in SNF or has an inpatient hospital for 60+ days or develops a new medical condition.

Reimbursement for OT and PT is based on a case-mix index from data collected in Section GG (3 self-care and 6 mobility items). SNFs receive the same payment each day for the first 20 days; then, reimbursement decreases every 7 days after that.

OT’s Role and Interventions

Plan of Care: Varies based on patient needs. Should consist mostly of 1:1 sessions and may use group/concurrent therapy. Of note, group/concurrent therapy can only be 25% of total therapy minutes per discipline per stay.

Length of Visit: Typically 30 minutes to 1 hour. Occasionally twice a day.

Focus of Visit: Discharge to home and independence.

Interventions:

  • Caregiver Training
  • ADLs and IADLs
  • Energy Conservation
  • Bed and Room Mobility
  • Equipment Recommendations
  • Functional Transfers
  • Orthotics
  • Chronic Disease Management

Typical Diagnoses

Diagnoses vary depending on the population. Many patients will be those who don’t qualify for long-term acute care, can’t tolerate inpatient rehab therapy requirements, and aren’t safe to discharge home. Wound care needs and long-term IV antibiotics may also qualify a patient for SNF. Common diagnoses include debility, failure to thrive, frequent falls, dementia, TBI, delirium, UTI, kidney disease, post-operative patients, post-COVID, COPD, etc.

Home Health

Admission Criteria

Patients qualify for home health if they are homebound and require the services of a skilled nurse, physical therapy, or speech therapy. Medicare defines homebound as individuals who have significant difficulty leaving the home. Patients are allowed to leave the home for specific activities such as church, doctor’s appointments, hair appointments, and food. OT is not a qualifying service under Medicare, so OT cannot be ordered alone at the start of care.

Reimbursement

Medicare Part A – The Patient-Driven Groupings Model (PDGM) is a case-mix adjusted model which functions similarly to a bundled payment. The Comprehensive Assessment, which includes the OASIS, determines the Home Health Resource Group (HHRG).

The HHRG considers diagnosis, comorbidities, functional level, and admission source when determining reimbursement. Agencies are paid in 30-day periods, but the certification is 60 days and is renewable. Reimbursement decreases every 30 days as the patient is anticipated to improve during that time.

Although OT is not a qualifying discipline at the start of care, OT can stand alone when other disciplines discharge. OT can also qualify a patient for recertification. Although therapy is not required under the home health benefits, CMS does not place any visit limits on medically necessary OT services. The clinician should determine the frequency and amount of therapy visits based on patient needs. OTs are permanently eligible to initiate the OASIS in therapy-only cases.

OT’s Role and Interventions

Plan of Care: 1-2 times a week or as short as 3-5 visits total.

Length of Visit: Typically 30 minutes for a regular visit and 1 hour for an eval.

Focus of Visit: Return to prior level of function, home safety, caregiver training, or discharge to outpatient.

Interventions: This is the time for occupation-based interventions to shine!

  • Caregiver Training
  • ADLs and IADLs
  • Functional Cognition
  • Community Mobility
  • Equipment Recommendations
  • Functional Transfers
  • Home Modifications
  • Chronic Disease Management

Typical Diagnoses

Diagnoses often consist of post-surgery, cancer, cardiac disease, post-COVID, COPD, post-injury, stroke, Parkinson’s, dementia, diabetes, and other chronic conditions.

Outpatient

Admission Criteria

Depending on the state, some patients can see an OT in outpatient without an order from an eligible clinician. Medicare does not technically require an order, but once the plan of care is established, a physician must certify the plan of care.

Most outpatient therapy takes place in clinics, but it may also be provided in the home. OT is a qualifying service for outpatient services even in the home.

Reimbursement

Medicare Part B – Billed through CPT® codes in a fee-for-service model. Chapter 15 of the Medicare Benefit Policy Manual primarily identifies what is required for coverage under Medicare Part B. OT services must be reasonable and necessary and require the skill of the identified clinician. Coverage is not based on diagnosis alone.

Therapy services over a certain monetary threshold must use a KX modifier to justify the necessity of care. The hard therapy cap was eliminated in 2018. Patients have a 20% coinsurance for Part B services. Some clinicians may be required to participate in the Merit-Based Incentive Payment System (MIPS). Additionally, clinicians must utilize the occupational therapy assistant modifier for Part B services provided by OTAs.

Clinicians can only bill Medicare for 1:1 time with the patient unless billing for group therapy. OT practitioners cannot bill Medicare beneficiaries out of pocket for services covered by Medicare because they cannot opt-out of Medicare.

OT’s Role and Interventions

Plan of Care: Varies but typically 2-3 times a week for 4-12 weeks.

Length of Visit: Typically 30 minutes to 1 hour.

Focus of Visit: Return to prior level of function, work, IADLs, strengthening.

Interventions: Focus on higher-level skills and return to prior level of function.

  • ADLs and IADLs
  • Fine Motor
  • Strengthening
  • Vision/ Coordination
  • Range of Motion
  • Orthotics/Splinting
  • Wound Care or Lymphedema
  • Chronic Disease Management
  • Neuromuscular Re-education
  • Pelvic Floor/ Women’s health

Typical Diagnoses

Diagnoses are often orthopedic or neurological in nature. Some clinicians may also specialize in lymphedema, pelvic floor, or hand therapy. The severity of injury greatly varies.

Hospice/Palliative

Admission Criteria

To be admitted to hospice, a hospice doctor or the patient’s doctor must verify that the patient is terminally ill with a life expectancy of 6 months or less. Patients must sign documents indicating they do not want other life-prolonging treatments. Patients must also sign a do not resuscitate (DNR) order. If a patient goes to the hospital, it often terminates hospice coverage. However, they can go back to hospice upon discharge. Hospice can be provided in the home, nursing home, or hospice house. Hospice houses are typically reserved for short-term stays and those who require constant oversight.

Reimbursement

Medicare Part A – Hospice services are billed as part of a bundled payment model. So, therapy services are not reimbursed separately from other services. Hospice may cover durable medical equipment (DME), pain management services, medical services, nursing, social services, aides, etc.

Not all patients in hospice or palliative care will receive therapy, but it is typically limited in quantity if they do. Hospice typically does not cover private caregivers beyond a bath aide. Occasionally, patients may receive therapy services under Part B, but it must be for a different diagnosis from the hospice qualifying diagnosis. Additional conditions may apply, and clinicians should seek further guidance if treating patients in hospice under Part B.

OT’s Role and Interventions

Plan of Care: Typically only a few visits

Length of Visit: Varies -depends on patient needs and tolerance

Focus of Visit: Adaptation instead of rehabilitation.

Interventions: Emphasis on quality of life and family training.

  • Life Roles and ADLs
  • Body Mechanics
  • Transfer Training
  • Home Evaluations
  • DME/AE Recommendations
  • Family Education/Training
  • Energy Conservation
  • Pain Management
  • Quality of Life/Legacy
  • Mental Health

Typical Diagnoses

Cancer is the most common diagnosis in hospice. Others include end-stage renal failure, cerebrovascular accident (CVA), amyotrophic lateral sclerosis (ALS), end-stage dementia, end-stage Parkinson’s disease, end-stage cardiac or respiratory disease, end-stage neurological disorders, end-stage AIDS, etc.

Medical Equipment

3-in-1 or Bedside Commodes

3-in-1 commodes can be used as a toilet frame, bedside commode, and shower chair. Of note, most patients cannot functionally utilize all three features as it would require frequent relocation and adjustment of the equipment. Patients are only eligible to receive a bedside commode if they are confined to one room, are confined to a floor there is not a toilet, or the home has no toilets.

Wheelchairs

Medicare covers wheelchairs if a patient cannot ambulate household distances which is typically considered 50 feet. A wheelchair assessment is important to complete before ordering a wheelchair so it can be custom fit the patient. Medicare will cover manual and motorized wheelchairs. However, they do not automatically cover motorized wheelchairs depending on the patient’s functional level. They do not cover wheelchairs for community mobility. Consulting a wheelchair specialist is helpful as wheelchairs are quite complex.

Hospital Beds

Hospital beds are covered if the patient’s condition requires specific body positioning and requires particular features that cannot be provided using an ordinary bed. Depending on the patient’s needs and equipment, the hospital bed may or may not be electric and have features such as adjustable head and foot and bed rails. Only specific diagnoses such as spinal cord or traumatic brain injury (TBI) patients can receive an electric hospital bed vs. a crank.

Mobility Devices

Mobility devices are covered under Medicare Part B as long as they are considered durable medical equipment (DME). Mobility devices include crutches, walkers, manual wheelchairs, electric wheelchairs, and scooters. Knee scooters are not covered.

Prosthetics

Medicare covers prosthetics such as artificial limbs, braces, and orthotics. However, prosthetics will only be replaced if these items cannot be repaired first.

Transfer Equipment

Medicare will cover a patient lift if the patient would be confined to the bed without it. This kind of equipment consists of Hoyer lifts or sit-to-stand lifts. This equipment may be rented or purchased with a copay. As with the hospital beds, transfer equipment may be operated manually or electric.

Definitions

ADLs

Activities of Daily Living: bathing, toileting, dressing, swallowing/eating, feeding, functional mobility, personal device Clare, grooming, sexual activity.

DRG

Diagnostic Related Group used for acute care hospital inpatients under medicare Part A and in LTCH. Reimbursement is based on the average utilization of services for Medicare patients in that DRG.

IADLS

Instrumental Activities of Daily Living: care of others, care of pets, child-rearing, communication management, driving/community mobility, finances, health management, home management, meal preparation, religious/spiritual activities, safety, shopping.

OASIS

Outcome and Assessment Instrument Set. The OASIS is used in home health during the start of care, recertification, and discharge. Information collected on this data is utilized for reimbursement and quality outcomes.

MIPS

Medicare Incentive Payment System. Utilized in outpatient settings billed under Medicare Part B that aren’t hospital-based. Occupational therapists are eligible to participate and may be required to depending on certain qualifiers.

NPI

National Provider Identifier is a unique identification number for covered health providers issued by CMS.

PDGM

Patient-Driven Groupings Model: Utilized in Home Health for Medicare Part A. Bundled payment system implemented on January 1, 2020.

PDPM

Patient-Driven Payment Model: Utilized in Skilled Nursing Facilities for Medicare Part A. Took effect October 1, 2019. PDPM eliminated Resource Utilization Group (RUG) levels.

Section GG

Section GG is a standardized assessment used in post-acute care to collect data related to function and functional mobility. In some settings, it is used to predict reimbursement.

Resources

Insurance Types

Payment Types

Quality Measures

Health Insurance

Acute Care

Long-Term Care Hospital

Inpatient Rehab Facility

Skilled Nursing Facility

Home Health

Outpatient

Hospice

About the Author

Clarice Grote, MS, OTR/L

Clarice Grote, MS, OTR/L is the founder of Amplify OT and an occupational therapist with experience in acute care, outpatient, lymphedema, and home health. She is also the host of the Amplify OT Podcast and founded the Amplify OT Membership. Clarice obtained her Bachelor of Arts from the University of Iowa in 2015 and earned her Masters of Science in Occupational Therapy from Columbia University in the City of New York in 2018. She served as the Missouri Occupational Therapy Association’s Director of Practice, the American Occupational Therapy Association’s Home and Community Health Special Interest Section Advocacy and Policy Coordinator, and an ambassador for the American Occupational Therapy Political Action Committee. Clarice is an accomplished speaker and author on Medicare policy, value-based care, and advocacy. Visit www.amplifyot.com/about-clarice to learn more. She can be reached at cgrote@amplifyot.com.

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Contains spam, fake content or potential malware

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