(Medicare Benefit Policy Manual)

EXAMPLE 4:   Where there is an unhealed, unstable fracture that requires regular exercise to maintain function until the fracture heals, the skills of a physical therapist would be needed to ensure that the fractured extremity is maintained in proper position and alignment during maintenance range of motion exercises.   EXAMPLE 5:   A Parkinson's patient or a patient with rheumatoid arthritis who has not been under a restorative physical therapy program may require the services of a physical therapist to determine what type of exercises are required to maintain the patient's present l evel of function or to prevent or slow further deterioration.  The initial evaluation of the patient's needs, the designing of a maintenance program appropriate to the patients capacity and tolerance and to the treatment objectives of the physician, the instruction of the patient, family or caregivers to carry out the program safely and effectively, and such reevaluations as may be required by the patient's condition, would constitute skilled physical therapy.  Each component of this process must be documented in the home health record.   While a patient is under a restorative physical therapy program, the physical therapist should regularly reevaluate the patient's condition and adjust any exercise program the patient is expected to carry out alone or with the aid of supportive personnel t o maintain the function being restored.  Consequently, by the time it is determined that no further restoration is possible (i.e., by the end of the last restorative session) the physical therapist will already have designed the maintenance program required and instructed the patient or caregivers in carrying out the program.  F.  Ultrasound, Shortwave, and Microwave Diathermy Treatments  These treatments must always be performed by or under the supervision of a qualified physical therapist and are skilled therapy.  G.  Hot Packs, Infra-Red Treatments, Paraffin Baths and Whirlpool Baths  Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications.  There must be clear documentation in the home health record, of the special medical complications that describe the need for the skilled services provided by the therapist.   H.  Wound Care Provided Within Scope of State Practice Acts   If wound care falls within the auspice of a physical therapist's State Practice Act, then the physical therapist may provide the specific type of wound care services defined in the State Practice Act.  However, such visits in this specific situation would be a covered therapy service when there is documentation in the home health record that the skills of a therapist are required to perform the service.  The patients response to therapy must be documented.   40.2.3 - Application of the General Principles to Speech -Language Pathology Services (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  The following discussion of skilled speech- language pathology services applies the principles to specific speech -language pathology services about which questions are most frequently raised.  Coverage of speech- language pathology services is not determined solely on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  Assuming all other eligibility and coverage requirements have been met, skilled speech -language pathol ogy services are covered when the individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified speech -language pathologist are necessary.  As described in 40.2.1(b), at defined points during a course of therapy, the qualified speech -language pathologist must perform the ordered therapy service visit, assess the patients function using a method which allows for objective measurement of funct ion and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patients clinical record.  Refer to 40.2.1(b) for specific timing and documentation requirements associated with these requirements.   1.  The skills of a speech -language pathologist are required for the assessment of a patient's rehabilitation needs (including the causal factors and the severity of the speech and language disorders), and rehabilitation potential.  Reevaluation would be considered reasonable and necessary only if the patient exhibited:    A change in functional speech or motivation;    Clearing of confusion; or    The remission of some other medical condition that previously contraindicated speech -language pathology services.   Where a patient is undergoing restorative speech- language pathology services, routine reevaluations are considered to be a part of the therapy and cannot be billed as a separate visit.   2.  The services of a speech -language pathologist would be covered if they are needed as a result of an illness or injury and are directed towards specific speech/voice production.  3.  Speech -language pathology would be covered where a skilled service can only be provided by a speech- language pathologist and where it is reasonably expected that the skilled service will improve, maintain, or prevent or slow further deterioration in the patients ability to carry out communication or feeding activities.   4.  The services of a speech -language pathologist to establish a hierarchy of speech-voice -language communication tasks and cueing that directs a patient toward speech -language communication goals in the plan of care would be covered speech -language pathol ogy.  5.  The services of a speech -language pathologist to train the patient, family, or other caregivers to augment the speech -language communication, treatment, to establish an effective maintenance program, or carry out a safe and effective maintenance progra m when the particular patients special medical complications require the skills of a qualified therapist (not an assistant) to perform a therapy service that would otherwise be considered unskilled or the needed therapy procedures are of such complexity t hat the skills of a qualified therapist are required to perform the procedures, would be covered speech- language pathology services.   6.  The services of a speech -language pathologist to assist patients with aphasia in rehabilitation of speech and language skills are covered when needed by a patient.  7.  The services of a speech -language pathologist to assist patients with voice disorders to develop proper control of the vocal and respiratory systems for correct voice production are covered when needed by a patient.   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   The following discussion of skilled occupational therapy services applies the principles to specific occupational therapy services about which questions are most frequently raised.  Coverage of occupational therapy services is not determined solely on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  Assuming all other eligibility and coverage requirements have been met, skilled occupational therapy services are cov ered when the individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified occupational therapist are necessary.   40.2.4.1 - Assessment  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Assuming all other eligibility and coverage requirements are met, the skills of an occupational therapist to assess and reassess a patient's rehabilitation needs and potential or to develop and/or implement an occupational therapy program are covered when they are reasonable and necessary because of the patient's condition.   As described in 40.2.1(b), at defined points during a course of therapy, the qualified occupational therapist (instead of an assistant) must perform the ordered therapy service visit, assess the patients function using a method which allows for objective  measurement of function and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patients clinical record.  Refer to 40.2.1(b) for specific timing and documentation requirements associated with these requirements.   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  The planning, implementing, and supervision of therapeutic programs including, but not limited to those listed below are skilled occupational therapy services, and if reasonable and necessary to the treatment of the patient's illness or injury would be cov ered.   A.  Selecting and Teaching Task Oriented Therapeutic Activities Designed to Restore Physical Function.   EXAMPLE: Use of woodworking activities on an inclined table to restore shoulder, elbow, and wrist range of motion lost as a result of burns.  B.  Planning, Implementing, and Supervising Therapeutic Tasks and Activities Designed to Restore Sensory -Integrative Function.   EXAMPLE:  Providing motor and tactile activities to increase sensory output and improve response for a stroke patient with functional loss resulting in a distorted body image.   C.  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.   EXAMPLE:  Use of sewing activities that require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient.   D.  Teaching Compensatory Techniques to Improve the Level of Independence in the Activities of Daily Living.   EXAMPLE:  Teaching a patient who has lost use of an arm how to pare potatoes and chop vegetables with one hand.  EXAMPLE:  Teaching a stroke patient new techniques to enable them to perform feeding, dressing, and other activities of daily living as independently as possible.  E.  The Designing, Fabricating, and Fitting of Orthotic and Self -Help Devices.   EXAMPLE:  Construction of a device which would enable a patient to hold a utensil and feed themselves independently.   EXAMPLE:  Construction of a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position.   F.  Vocational and Prevocational Assessment and Training   Vocational and prevocational assessment and training that is directed toward the restoration of function in the activities of daily living lost due to illness or injury would be covered.  Where vocational or prevocational assessment and training is related  solely to specific employment opportunities, work skills, or work settings, such services would not be covered because they would not be directed toward the treatment of an illness or injury.  40.2.4.3 - Illustration of Covered Services  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3118.2.D.3, HHA -205.2.D.3  EXAMPLE 1:   A physician orders occupational therapy for a patient who is recovering from a fractured hip and who needs to be taught compensatory and safety techniques with regard to lower extremity dressing, hygiene, toileting, and bathing.  The occupational therapist  will establish goals for the patient's rehabilitation (to be approved by the physician), and will undertake teaching techniques necessary for the patient to reach the goals.  Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment.  Such visits would be considered covered when the skills of a therapist are required to perform the services.  The patients needs in response to therapy must be documented.   EXAMPLE 2:   A physician has ordered occupational therapy for a patient who is recovering from a CVA.  The patient has decreased range of motion, strength, and sensation in both the upper and lower extremities on the right side.  In addition, the patient has perceptual  and cognitive deficits resulting from the CVA.  The patient's condition has resulted in decreased function in activities of daily living (specifically bathing, dressing, grooming, hygiene, and toileting).  The loss of function requires assistive devices to ena ble the patient to compensate for the loss of function and maximize safety and independence.  The patient also needs equipment such as himi-slings to prevent shoulder subluxation and a hand splint to prevent joint contracture and deformity in the right hand.  The services of an occupational therapist would be necessary to:   Assess the patient's needs;    Develop goals (to be approved by the physician);   Manufacture or adapt the needed equipment to the patient's use;   Teach compensatory techniques;   Strengthen the patient as necessary to permit use of compensatory techniques; and    Provide activities that are directed towards meeting the goals governing increased perceptual and cognitive function.  Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment.  Such visits would be considered covered therapy services when the skills of a therapist are r equired to perform the services.  The patients needs, course of therapy and response to therapy must be documented.  50 - Coverage of Other Home Health Services  (Rev. 1, 10-01-03) A3-3119, HHA-206  50.1 - Skilled Nursing, Physical Therapy, Speech -Language Pathology Services, and Occupational Therapy  (Rev. 1, 10-01-03) A3-3119.1, HHA-206.1