9-23-05
Successful Advocacy Leads to Medicare LCD Changes
AOTA members, your requests for assistance with Medicare local coverage determinations (LCDs) have been fruitful! AOTA's Reimbursement and Regulatory Policy Department (RRPD) wants you to know that it has been successful in overturning a number of Medicare LCD policies that threatened to limit the occupational therapy scope of practice.
This is only the beginning of the positive results we hope to achieve for occupational therapy with respect to Medicare LCDs. Below are brief summaries of the successful Medicare LCD advocacy results AOTA has achieved recently.
Cahaba GBA (Iowa Medicare) Outpatient Occupational Therapy LCD
AOTA collaborated with IOTA President Denise Behrends and member Helen Cohen to challenge Cahaba's draft Outpatient Occupational Therapy LCD. AOTA opposed Cahaba's lack of coverage for vestibular rehabilitation services and submitted a formal comment letter with relevant medical literature that supported the efficacy of vestibular rehabilitation. As a result, the LCD no longer restricts vestibular rehabilitation services. View the final LCD.
Blue Cross Blue Shield (BCBS) of Georgia (Georgia Medicare) Occupational Therapy LCD
AOTA worked with member Mary Ann Wood to advise her in pursuing a reconsideration of the BCBS of Georgia Occupational Therapy LCD. Ms. Wood and her facility submitted a reconsideration letter to BCBS of Georgia requesting the revision of the existing policy to include coverage for the following ICD-9 diagnostic codes: late effects of cerebrovascular disease (438.0-438.89); neurological neglect syndrome (781.8); and postmasectomy lymphedema syndrome (457.0), among others. Together, our efforts were successful in achieving the addition of these diagnoses to the Occupational Therapy LCD, effective August 1, 2005. View the final LCD.
HGSAdministrators' (HGSA) Occupational Therapy LCD
AOTA collaborated with Pennsylvania member Chris Chovan in successfully advocating with HGSA, a Part B Medicare carrier for clear coverage of assistive technology assessments provided by occupational therapists. Together, AOTA and Mr. Chovan convinced HGSA to reconsider their Outpatient Occupational Therapy LCD with respect to the assistive technology code (CPT 97755). In the process of considering AOTA's request for reconsideration, HGSA identified a claims processing issue that was causing automatic denials of CPT 97755. As a result, OTs who received denials for billing this code now have the opportunity to appeal their denial or resubmit their claim for payment (if the appeals deadline has passed). In addition, HGSA agreed to revise its LCD when it comes up for revision in 2006 to clarify its coverage of the assistive technology code. See a copy of AOTA's reconsideration letter and HGSA's subsequent positive response.
Palmetto GBA Home Health Skilled Nursing Care - Teaching and Training: Alzheimer's Disease and Behavioral Disturbances LCD
AOTA collaborated with Palmetto GBA's Medical director, Dr. Feliciano, to comment on the LCD titled "Home Health Skilled Nursing Care - Teaching and Training: Alzheimer's Disease and Behavioral Disturbances LCD." Dr. Feliciano specifically reached out to AOTA because of his interest in the use of the International Classification of Functioning, Disability and Health (ICF) as a system for discussing behavioral disturbance and medical coverage, and the similarities of the ICF to the occupational therapy Framework.
While AOTA supported Palmetto's use of the ICF, AOTA raised concerns that the skills of occupational therapists are needed to address the care of Medicare beneficiaries with Alzheimer's disease and behavioral disturbances in the home health setting, which was not addressed in the LCD. AOTA requested that Palmetto revise its LCD titled "Occupational Therapy for Home Health" to recognize the role of occupational therapists with beneficiaries who have Alzheimer's disease and behavioral disturbances. AOTA also requested in a letter that Palmetto recognize the importance of an interdisciplinary approach to the care of these beneficiaries. Palmetto agreed to our requests and will be revising the Occupational Therapy for Home Health LCD shortly.
Remember, we need your assistance to continue to monitor and respond to these issues quickly and effectively. Please continue to let the Reimbursement and Regulatory Policy Department know if you run across a draft LCD that is up for comment or that is negatively affecting you. Also, remember to contact your state association to learn if your reimbursement issue is also affecting other occupational therapists in your region.
