HCHSIS FAQs
Question 1: Can occupational therapists do the OASIS (comprehensive assessment) in home health?
Question 2: What is the status of making occupational therapy a qualifying service under the Medicare home health benefit? How can that be accomplished? What can a practitioner do?
Question 3: What should occupational therapists providing outpatient therapy understand about the Medicare home health benefit? What do occupational therapists in home health need to understand about bundled services, including outpatient occupational therapy, in home health?
Question 4: I'm a new graduate. I was told that I need 2 years of experience to work in home health, but was just hired in that area. I have lots of questions. Where can I get some answers?
Question 5: What are the rules for supervising an occupational therapy assistant in home health?
Question 6: Where can I find out more about OASIS, home health PPS, and OBQI?
Community Practice Question: I'm interested in developing a nontraditional practice in the community. How do I get started?
Home Modifications Question: If I work as an occupational therapist in home modifications, do I need a referral or prescription from a physician?
Question 1: Can occupational therapists do the OASIS (comprehensive assessment) in home health?
Answer: Yes, occupational therapists can conduct the start of care comprehensive assessment, including the OASIS, in cases where the occupational therapist establishes eligibility for home health services. (See U.S.Code of Federal Regulations Title 42 CFR 409.42C.) While the need for occupational therapy alone does not establish eligibility under Medicare Part A, it may establish eligibility under some state Medicaid programs or for other third party payers. In these cases, occupational therapists may perform the start of care comprehensive assessment for rehab-only cases. At subsequent time points (e.g., transfer, resumption, recertification, significant change in condition [SCIC], discharge) the regulations do not specify any particular discipline.
The regulations do specify that the comprehensive assessment must be performed by a registered nurse, physical therapist, occupational therapist, or speech and language pathologist. An occupational therapy assistant cannot conduct the comprehensive assessment or complete the OASIS.
However, as a matter of best practice in documentation, the transfer and discharge assessments are to be based on the patient status at the time of the most recent skilled visit and should be done by the clinician responsible for that visit. For the SCIC, the clinician who recognizes the change and obtains the revised physician order would be the most appropriate to perform the assessment.
A single clinician is responsible for completing each OASIS; therefore, there is no "section" that an occupational therapist should be completing.
Question 2: What is the status of making occupational therapy a qualifying service under the Medicare home health benefit? How can that be accomplished? What can a practitioner do?
Answer: Legislation has been introduced by U.S. Representative Rob Andrews (D-NJ) to make occupational therapy a qualifying service. The legislation is called the Medicare Occupational Therapy Coverage Eligibility Act of 2005 (H.R. 3022). There is no legislation yet in the Senate, so we need a Senate sponsor. Visit this page for more information.
Because the Medicare home health benefit is defined in federal law, a legislative change is the only way for occupational therapy to become a qualifying service under the home health benefit. Contact your Representative to be a cosponsor of this legislation. Contact your Senator to introduce legislation in the Senate or to be a sponsor of legislation after it is introduced. If you work in home health, notify your administrators of the proposed legislation and suggest their support. Ask whether you can share the information within your agency, or share information on how your coworkers can contact Congress to urge support of the bill. Also, promote the use of occupational therapy under current home health law. Provide materials to explain what occupational therapy can accomplish for home health patients. To download the Home Health Fact Sheet visit "Fact Sheets on the Role of OT" at right under "Related Content".
Get involved in your home health agency's Outcomes-Based Quality Improvement (OBQI) efforts. This is a good way to build support for occupational therapy within the industry. As home health under Medicare moves into a Pay for Performance model, the contributions of occupational therapy to client outcomes will have an even greater impact on agencies. The more agencies understand occupational therapists' expertise in assessing and addressing functional performance areas, the more likely they will be to use occupational therapy. This also builds support in the industry for legislative changes to make occupational therapy a qualifying service.
Question 3: What should occupational therapists providing outpatient therapy understand about the Medicare home health benefit? What do occupational therapists in home health need to understand about bundled services, including outpatient occupational therapy, in home health?
Answer: Under the Home Health PPS, rehabilitation services (occupational therapy, physical therapy, and speech and language pathology) are "bundled." This means that if a client is receiving services under a Medicare A home health plan of care, all services that fall under that benefit are "bundled" under a single payment. Such services cannot be "unbundled"-they cannot be billed separately by the home health agency or by another provider even if they are billable under a different Medicare benefit (part B).
If you are a practitioner providing services under part B, you should verify the status of each new Medicare beneficiary. This can be done by asking the person or verifying with the Medicare system (this can be done electronically). If the person is under a home health plan of care and receiving services from a home health agency, you should notify the person and the referral source that the home health agency is responsible for addressing the person's therapy needs.
If the referral is for a service that could not be provided in the home (e.g., whirlpool, specialized orthotic fabrication), the home health agency must set up a contractual arrangement with an outpatient provider. The home care agency is responsible for the care provided under the contract, and it must meet all the regulations and standards that govern the home health agency. The arranged outpatient services must be included on the home health plan of care (Form 485).
The outpatient provider must seek payment from the home health agency (as arranged in the contract) and the agency will pay the outpatient provider from the home health episode payment. If an outpatient provider submits a Part B claim for service dates that occur during a home health episode (plan of care), the outpatient claim will be denied. The home health agency is under no obligation to pay the outpatient provider for services not provided under the arrangement and not identified in the home health plan of care.
If a Medicare beneficiary is already receiving outpatient services from you and that person is referred to home health services, the agency must determine whether the home health coverage criteria have been met before initiating a home health plan of care. Since a beneficiary must be homebound to receive services under the home health benefit, there may be a question of whether the client actually is homebound if he or she was able to access outpatient therapy outside the home at the time of the home health referral. If the home health coverage criteria are met, the outpatient provider should discharge the client to the care of the home health agency, which will address the therapy needs under the home health plan of care.
If you are an occupational therapist in home health, you must be alert to the possibility that your home health clients may be referred to outpatient therapy while they are under a home health plan of care. This can happen when more than one physician is involved (e.g., one physician orders home care and another orders outpatient therapy and the client follows up with both), or a home health client is seen for a follow-up by a physician at a health care facility and the physician arranges for a therapist to see the client in conjunction with the physician appointment. In both of these cases, the outpatient therapy would not have been provided under arrangement and the Medicare Part B claim for outpatient therapy services would not be paid. In addition to having a contract for the services, the home health agency must include the outpatient services orders on the 485 and include documentation of the services in the record.
If you have a client who needs therapy services that cannot be provided in the home, your agency must arrange a contract with a provider of these services and coordinate the services as part of the home health plan of care. The services will be provided away from the home under the auspices of the home health agency, will be included in the home health plan of care, and will be paid for under the terms of the contract between the home health agency and the outpatient provider. Receipt of services in this situation should not, in and of itself, compromise the client's homebound status (since it involves leaving home for medical appointments).
Both outpatient and home health providers need to make themselves aware of any services that the client is receiving. Providers must communicate to ensure that clients are served in the most appropriate setting and to coordinate any billing and documentation issues.
Question 4: I'm a new graduate. I was told that I need 2 years of experience to work in home health, but was just hired in that area. I have lots of questions. Where can I get some answers?
Answer: Welcome to a challenging and rewarding practice setting. Home health agencies that are Medicare certified must adhere to the Conditions of Participation, which are federal regulations that govern how the agencies operate. The federal regulations state (42 CFR §484.4) the following:
Personnel qualifications
"'Occupational Therapist.' A person who:
(a) Is a graduate of an occupational therapy curriculum accredited jointly by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association; or
(b) Is eligible for the National Registration Examination of the American Occupational Therapy Association; or
(c) Has 2 years of appropriate experience as an occupational therapist, and has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service, except that such determinations of proficiency do not apply with respect to persons initially licensed by a State or seeking initial qualification as an occupational therapist after December 31, 1977.
'Occupational Therapy Assistant.' A person who:
(a) Meets the requirements for certification as an occupational therapy assistant established by the American Occupational Therapy Association; or
(b) Has 2 years of appropriate experience as an occupational therapy assistant, and has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service, except that such determinations of proficiency do not apply with respect to persons initially licensed by a State or seeking initial qualification as an occupational therapy assistant after December 31, 1977."
As you can see, experience was an alternative criterion for practitioners and does not apply to practitioners who were certified or licensed after December 31, 1977. The wording of the section itself is out of date, as now the Accreditation Council for Occupational Therapy Education (ACOTE) is the organization that accredits curricula and the National Board for Certification in Occupational Therapy, Inc. (NBCOT)is the organization that administers the certification examinations, but these standards (graduation from an accredited program or eligibility to take the certification examination) are the current standards. There is no standard set by Medicare for prior practice experience.
However, there may be state regulations that govern the operations of a home health agency or the practice of occupational therapy that do require a specific level of experience for an occupational therapist or occupational therapy assistant to practice in home health. You can check with the agency or board that governs occupational therapy practice in your state and with your state's home health association for more specifics.
If the agency is accredited (by JCAHO, the Community Health Accreditation Program [CHAP], or another organization), there is yet another set of standards that must be consulted regarding practitioner credentials and experience. The agency should know the current standards for accreditation, or you can check with JCAHO or CHAP for more information.
The practical answer to the question of experience is related to your ability to access adequate supervision and mentoring to provide competent and ethical practice. Home health practice includes a fair amount of isolation and "thinking on your feet" in a patient's home, where there are not other professionals present to offer advice or guidance. If you do not have much practice experience, how will you receive guidance? Who can/will you call upon as a resource as you develop your home health practice repertoire? At many home health agencies, there is only one occupational therapist. If you will be that one therapist, will the agency support you by helping provide a network of resources and mentors, or will you need to establish that on your own? If there are other occupational therapy practitioners, will they be available to you as a resource? If you are an occupational therapy assistant, will you have access to supervision (including supervised patient visits) that is consistent with your experience and competency? These are questions you want to resolve before deciding to work at a particular agency as a new graduate or recent graduate.
The HCHSIS listserv provides networking that reduces isolation and creates a virtual "community" of home health practitioners. The HCHSIS provides resources such as practice articles in the Quarterly and continuing education articles in OT Practice. Your state association also may have a practice section or network for home health practitioners.
Question 5: What are the rules for supervising an occupational therapy assistant in home health?
Answer: The federal regulations that govern Medicare-certified home health agencies require supervision of occupational therapy assistants, but do not provide specifics about the intensity, type, or frequency of supervision. However, the standard should be no less than "general supervision" as defined in other Medicare settings. Your state occupational therapy regulations and home health licensing regulations may have specifics about supervision of occupational therapy assistants. If your agency is accredited by JCAHO or CHAP, these accrediting organizations also may have standards for supervision of assistants. You will need these sources for an answer.
Question 6: Where can I find out more about OASIS, home health PPS, and OBQI?
Answer: There are resources from the Centers for Medicare and Medicaid (CMS, [formerly HCFA]) on the Internet. The OASIS Web site includes FAQs, regulations, and a training page with information about OBQI and OBQM (adverse outcomes reports).
The Home Health Agency Center includes links to questions and answers about PPS and other background information about this payment system.
These resources provide practitioners with a better understanding of the regulations and payment for home health services. Consultants and trainers in the home health industry use these resources to advice agencies. These sites give you the same access and information.
Community Practice Question: I'm interested in developing a nontraditional practice in the community. How do I get started?
Answer: There are many opportunities to develop a practice in the community, and the answer depends on the experience and knowledge you have, your interests, the needs of your community, and your entrepreneurship. Because there are many facets to the question, the HCHSIS promotes emerging practice by identifying and sharing examples of community-based practice and encouraging those who are developing such practices to share their experiences with others.
The HCH SIS Quarterly archives include a number of articles by practitioners who have developed new community-based practices. In these articles, practitioners share practical strategies they employed to decide what service was needed, how they developed and marketed their idea, and what they are learning from the process. AOTA members can access the archives online.
The HCH SIS Quarterly regularly features relevant articles and the editor is always looking for models of community practice to highlight. In addition, there are several relevant articles in OT Practice. For example, the Continuing Education article in the July 2004 issue was focused on occupational therapy for community populations.
If you are interested in developing a private practice, you also should consider joining the Private Practice Subsection of the Administration and Management SIS. If you are interested in becoming a private practitioner participating in the Medicare program (Medicare OT in Private Practice [OTPP]), check the AOTA Web site. For specifics on how to become a Medicare provider go to http://www.cms.hhs.gov/home/medicare.asp. You need to check with your state regulatory board to determine if your state requires a physician referral to initiate an occupational therapy evaluation or treatment. Depending on the population(s) you propose to serve, research the documentation requirements of third party payers and sources of community funding to pay for your services.
Home Modifications Question: If I work as an occupational therapist in home modifications, do I need a referral or prescription from a physician?
Answer: Check with your state licensure laws and practice acts regarding the need for a physician's referral. Your state practice act defines the practice and the practitioner.
Licensure information and also the scope of practice for each state can be found on the AOTA Web site under "Practitioners, Licensure" or in "Related Content" at the right.
Consider what type of payment you will be accepting. If you will bill to a third party payer, such as Medicare or an insurance company, you will also need to follow their regulations regarding physician referral.
You can benefit from establishing a relationship with physicians. They can help you meet your state regulations regarding physician referral, but physicians also can help to grow your practice by providing unsolicited referrals.
01/24/06
