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Occupational Therapy May Be The Most Appropriate Discipline To Utilize In Order To Establish and Maintain Continuing Medicare Home Health Services Coverage For A Chronic Cognitive and Behavioral Health Condition Based Medicare Patient.

A. To qualify for occupational therapy services under the Medicare home health services benefit, a Medicare beneficiary must be confined to the home; under the care of a physician or allowed practitioner; receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner; and have a continuing need for occupational therapy.

See § 30 – Conditions Patient Must Meet to Qualify for Coverage of Home Health Services (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21) ; Medicare Benefit Policy Manual Chapter 7 – Home Health Services

B. Occupational therapy may be utilized for patients who need occupational therapy services in the home not only to improve function , but also to maintain function, as coverage of occupational therapy services is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled occupational therapy care.

Where the patient meets the qualifying criteria in § 30 , Medicare covers …occupational therapy that meets the requirements of § 40.2. ….

See § 50.1 – Skilled Nursing, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy (Rev. 1, 10-01-03) A3-3119.1, HHA-206.1 ; Medicare Benefit Policy Manual Chapter 7 – Home Health Services

The service of a … occupational therapist …. To be covered, assuming all other eligibility and coverage criteria have been met, the skilled services must also be reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury. …

See § 40.2.1 – General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21), Medicare Benefit Policy Manual Chapter 7 – Home Health Services HHA-206.1

Coverage of occupational therapy services is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled occupational therapy care . Assuming all other eligibility and coverage requirements have been met, skilled occupational therapy services are covered when the individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified occupational therapist are necessary.

See § 40.2.4 – Application of the General Principles to Occupational Therapy (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3118.2.D, HHA-205.2.D; Medicare Benefit Policy Manual Chapter 7 – Home Health Services

C. Occupational therapy can be the only therapy service needed by the patient in order to establish and maintain continuing eligibility for the Medicare home health services benefit. A continued need for occupational therapy can extend eligibility under Medicare because the need for occupational therapy alone qualifies Medicare patients for continuation of the home health services benefit.

Occupational therapists can conduct the initial assessment visit and the start of care comprehensive assessment on therapy-only patients for whom occupational therapy “establishes eligibility” See 42 CFR § 484.55 Conditions of Participation, Comprehensive Assessment Of Patients

….Subsequent to an initial covered occupational therapy service [visit], continuing occupational therapy services which meet the requirements of §409.44(c) are considered to be qualifying services See 42 CFR § 409.42(c)(4)) Beneficiary qualifications for coverage of services, .

D. The planning, implementing, and supervision of therapeutic programs including, but not limited to the planning, implementing, and supervising of individualized therapeutic activity programs as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness, are skilled occupational therapy services, and if reasonable and necessary to the treatment of the patient’s illness or injury they would be covered.

See § 40.2.4.2 – Planning, Implementing, and Supervision of Therapeutic Programs (Rev. 1, 10-01-03) A3-3118.2.D.2, HHA-205.2.D.2 ; Medicare Benefit Policy Manual Chapter 7 – Home Health Services

EXAMPLE: Use of sewing activities that require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient

Postscript : Occupational therapy has a vital role in home health services care. Occupational therapists assess and evaluate the patient’s home environment, evaluate functional status, identify possible safety issues, and identify other needs and strategies immediately , such as daily management of chronic conditions and adherence to daily medication administration routines. See the American Occupational Therapy Association ( AOTA) Fact Sheet On Occupational Therapy’s Role In Home Health @ https://www.aota.org/about-occupationaltherapy/professionals/pa/facts/home-health.aspx

As management of chronic conditions is in large part management of daily activities , occupational therapy brings expertise to help home health care recipients towards manageable daily habits and routines. With a core knowledge base in psychosocial issues, occupational therapists can address behavioral health conditions and train caregivers to provide appropriate cues and support to patients with cognitive limitations to optimize performance and reduce agitation or confusion. See the American Occupational Therapy Association ( AOTA) Fact Sheet On Occupational Therapy’s Role In Home Health @ https://www.aota.org/about-occupationaltherapy/professionals/pa/facts/home-health.aspx

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ESTABLISHING & CONTINUING MEDICARE HOME HEALTH SERVICES THROUGH CONTINUING NEED FOR OCCUPATIONAL THERAPY