Private practice essentials for reimbursement

Review important documentation resources from AOTA

Good documentation is essential for proper reimbursement. Documentation should justify the medical necessity of the service while providing a clear picture of the client’s limitations, goals, and functional outcomes. Below are a few general documentation guidelines and a wealth of AOTA resources that provide more detailed information. Medicare documentation is often viewed as the standard for documentation, so you should review their requirements closely. Commercial insurance companies and other payers may have their own specific requirements that must be adhered to for reimbursement and utilization review purposes, so you are urged to take note of any additional standards listed in the provider manuals for each payer.

• Document treatment time spent on each intervention.
• Document client-centered goals and outcomes.
• Document specialized skills needed to qualify as a skilled service.
• Link interventions to performance outcomes.
• Clearly state intervention approaches.
• Document the type of assessment used and the results of the assessment.
• Document clear recommendations and goals of continued treatment.
• Document the client’s response to treatment.

More detailed information on documentation can be found in the Resources section of this Guide.

Maintenance care is covered under Medicare “…when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (”skilled care”) are necessary for the performance of an effective maintenance program…to maintain the patient’s current condition or to prevent or slow further deterioration…”

In order for Medicare to cover maintenance, you need to effectively demonstrate in the documentation that skilled services are required.  

Read about the Jimmo Settlement.

Several situations can result in having to treat different areas or conditions for the same client. For example, a client under a plan of care for low vision could fall and need treatment following a fracture. Or a client may injure another finger while compensating for the use of a splint. Different cases will require different methods of billing.

• New condition requiring new plan of care—In the first example, the client is under a plan of care for low vision. Then the client falls and sustains a hip fracture, which is completely separate from the low vision intervention and requires a new plan of care. In this situation, a new evaluation would be done for the hip fracture, and treatment for the two conditions must be conducted, documented, and billed separately.
• New condition requiring a revised plan of care—In the second example, the second injury occurred due to the treatment for the initial injury. Treating the additional finger would require a revised plan of care that includes the new diagnosis, and could be conducted, documented, and billed at the same time as the treatment for the initial injury.
• Co-treatment—Some clients may benefit from treatment by both an OT and a PT or SLP at the same treatment session. The rationale for the co-treatment and the goals of the session should be clearly documented. Total time for the session is split between the two disciplines. For example, if the total face-to-face time spent with the client is 60 minutes, the OT will bill 30 minutes and the PT or SLP will bill 30 minutes. For more information on co-treatment, review the joint statement from AOTA, APTA, and ASHA found under the Resources section.

Keep in mind that the services may be denied upon initial submission and may require an appeal for the denial to be overturned and paid.