Coverage of - WVTRA - West Virginia Therapeutic Recreation

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Transcript Coverage of - WVTRA - West Virginia Therapeutic Recreation

Coverage of Therapeutic
Recreation in Clinical
Tim Passmore, Ed.D., CTRS
West Virginia Therapeutic Recreation
Association Annual Conference
Oklahoma State University
What is Considered to be Active
Treatment by the Center for Medicare &
Medicaid Services (CMS)?
• Any intervention which
What Settings Require Active
Inpatient psychiatric services
Partial hospitalization services
Inpatient Physical Rehabilitation services
Acute care services
Public school systems
Recreational Therapy
Active Treatment
• Therapeutic Recreation interventions that are functional in nature
… standing X 10 minutes without assistance to complete table top leisure task
Identify X 1 coping mechanism to assist with ….
Ambulate X 175 within community…
What are some others????????
• Treatment session terminology
Community reintegration sessions
Life management
Task sessions – in place of arts & crafts
Prescriptive therapy sessions – in place of exercise group, walking group,
relaxation group
– Etc…
Recreational Therapy
Diversional Activities/Non-Active Treatment
• Recreation Activity/Diversional activity
Movie night
• There is therapeutic value
– Just not covered by 3rd party Payors
• Maintenance and/or Palliative care!
– Except in Long-term Care
– Hospice
Who Makes Decisions Regarding
What Is a Covered Service?
Centers for Medicare & Medicaid Services
Fiscal Intermediaries
Quality Improvement Organizations
Facility Administrators
Departmental Managers
Allied Health Professionals
Who Makes Decisions Regarding
What Is a Covered Service?
• HCFA/CMS – Health Care Financing
Administration/Centers for
Medicare/Medicaid Services
– Federal agency
– Responsible for administration of Medicare &
• CMS – makes the rules/regulations
Who Makes Decisions Regarding
What Is a Covered Service?
Intermediaries (FI) – (Medicare)
Process claims
Inpatient & outpatient
Each state will have one
Mediates disputes between hospitals and PROs
Issue Local Coverage Determinations (LCDs)
Quality Improvement Organizations formerly known as Peer Review Organizations
(PRO) – (Medicare)
– Determine if a service is reasonable, necessary and provided in correct setting
– Each state has one
Administrators of Treatment Facilities
– Directors of
Activity Therapy
Physical Medicine
Fiscal Intermediary
• Most powerful entity outside of CMS
• System is changing
• From FI to MAC
– Medicare Administrative Contractor (MAC) – Combined management of Part A
– First contract awarded
• Noridian Administrative Services, LLC – Fargo ND
North Dakota
South Dakota
• Noridian Administrative Services – has current statement
– Which would include Recreational Therapy
• Next MAC contract will manage
– Colorado, Oklahoma, New Mexico & Texas
Quality Improvement Organizations
• Cornerstone in efforts to improve
quality/efficiency of delivery of care
Improve quality
Reduce improper payments for inpatient facilities
Address beneficiary complaints
Mediation between healthcare providers and patients
• All are concerned with
Generating dollars
Protecting dollars
Complying with regulations
Keeping their job
Inpatient Psychiatric Setting
• Inpatient Psychiatric Facility (IPF)
• 20.1.2 – Services Expected to Improve the Condition or for
Purpose of Diagnosis, A3-3102.1.A.2, HO-212.1A2 of the
Medicare Benefit Policy Manual Chapter 2.
– Specifically identified Recreational Therapy/Therapeutic
Recreation as an adjunctive therapy
• Recreational Therapy & Occupational Therapy
– Replaced with the term Therapeutic Activities
– Per CMS communication did not alter the method of
payment for Recreational Therapy in a IPF
Regulations – Inpatient Psychiatric
Treatment Facilities
• “If the only activities prescribed for the patient
are primarily diversional in nature, (i.e. to
provide some social or recreational outlet for the
patient), it will not be regarded as treatment to
improve patients’ conditions.”
Inpatient Physical Rehabilitation
Inpatient Physical Rehabilitation Facility (IRF)
7 Screening Criteria for IRF
Close medical supervision
24 hour rehabilitation nursing
“3-hour Rule” relatively intense level of rehabilitation
Multidisciplinary team
Coordinated care program
Significant practical improvement
Realistic treatment goals & objectives
Inpatient Physical Rehabilitation
Centers for Medicare & Medicaid Services
42 CFR Part 412
RIN 0938-AL95
Medicare Program; Changes to the Inpatient Rehabilitation Facility Prospective Payment System and Fiscal Year 2004 Rates
Posted August 1, 2003
Page 119
Intermediaries with respect to their scope of discretion, as well as, provide them with instructions to implement all revisions to the outlier policy contained in
this final rule.
I. Miscellaneous Comment
Comment: We received a comment expressing a concern that some providers believe that recreational therapy services are not covered by Medicare and that
the costs of providing recreational therapy services are not included in the IRF PPS rates.
Response: This comment is not specifically related to our proposed changes to the IRF PPS. We responded to similar comments in the IPPS January 3,
1984 final rule (49 FR 242) by stating that "Neither the implementation of the prospective payment system nor the criteria for excluding certain hospitals
and units from it will prohibit the provision of recreational therapy services to hospital inpatients. In particular, the absence of these services from the list of
rehabilitative services in rehabilitation hospitals and units does not indicate that Medicare will no longer pay for them in those hospitals and units that
provide them. On the contrary, these services will continue to be covered to the same extent they always have been under the existing Medicare policies."
Since the publication of the January 3, 1984 final rule, we have not made any changes to our policies that would preclude recreational therapy services from
those covered by Medicare. In particular the introduction of the IRF PPS does not change this fact. Accordingly, since recreational therapy services were
provided in the IRF base period, the costs of providing these covered services are included in standardized payment amount upon which the IRF PPS rates
are based”.
Figure 7.1 – Department of Human Services – Centers for Medicare & Medicaid Services – 42 CFR Part 412 [CMS-1474-F] RIN 0938-AL95
The Term Recreation
• Recreational Therapy/Therapeutic Recreation
– Often not given similar consideration as
• Other allied health profession
• Because of the term recreation
• Regulations
– Specifically state – don’t not pay or cover
How Do I Establish the Framework
for Coverage of Services
• Become familiar with state and federal regulations
– Based on treatment setting
• Familiarize self with Professional Standards of Practice
• Know who your 3rd Party Payors
– Medicare
– Medicaid
– Insurance companies
• Administrative support at the facility level
Steps to Obtaining Coverage
Physician’s Orders
Goals & Objectives
Treatment Plan
Delivery of Services or Interventions
Documentation of Provision of Services/Interventions
Discharge Recommendations & Summary
Steps to Obtaining Coverage
• Follow the Therapeutic Recreation Process
Formula for Establishing Unit
Salaries & Benefits
Operational Expense
$ 209,440
Administrative/Clerical Support
$ 656,000
Overhead @ 40%
Total Costs
Cost per hour of patient care: (Divide total cost by number of hours of patient
• $4,057,536 Total Cost/Year divided by 20,000 Hours of Patient Care/Year =
• Cost per unit of patient care: (Divide cost per hour by 15 min [or unit time] equals
dollars per 15 min unit charge) $202.88/4 = 50.74 per unit or 15 minutes
• *Overhead is calculated at 40 percent of direct costs. It includes various indirect
expenses such as heating/cooling, electric, printing, maintenance, and housekeeping.
Used by Permission: Carter, Van Andel, & Robb – Waveland Press, INC.
Subject: Systematic Handling of Unit
The Recreational Therapy Department will record daily unit charges prior to leaving the
treatment facility at the noon hour and at the end of the day. Time allocation for
triggering unit recording will consist of more than 1 minute spent with a patient of this
treatment facility will equal 1 unit charge.
Recreational Therapists will record unit charges in 15 minute increments
utilizing the unit charge slips in the appropriate charge category.
Recreational Therapists will record 1, 2, or appropriate numeric unit charge
representing time allocation per patient to represent time spent providing active
Recreational Therapists will sign and date unit charge slips on a daily basis.
Recreational Therapists will turn in completed unit charge slips to rehabilitation technician
prior to final departure from treatment facility.
Subject: Unit Productivity
The Recreational Therapy Department will calculate daily
productivity by tallying daily treatment facility unit charges.
Each Recreational Therapist will be responsible for a
minimum daily productivity level of 24 units.
The rehabilitation technician will tally the actual daily
productivity level of each recreational therapist.
The rehabilitation technician will record the daily
productivity level of each recreation therapist in the
productivity log book.
Medicare Part A & B
• Medicare Part A – has regulatory governance
Inpatient hospitals
Critical access hospitals
Skilled nursing facilities
Some home health
• Medicare Part B – has regulatory governance
Specific medically necessary services
Home health
Outpatient hospital care
Prospective Payment System
• Based on Diagnostic Related Groups (DRGs)
• Payment based on groupings of diagnosis
– Adjusted related location within USA
Prospective Payment System
• Areas
– Inpatient Physical Rehabilitation Facilities (IRF PPS)
– Inpatient Psychiatric Facilities (IPF - PPS)
– Long-term Care Facilities (LCT - PPS)
Local Coverage Determinations
• IRF – LCD which include RT/TR in the “3-hour Rule”
– AdminaStar Federal
• IL, IN, OH, KY
– Anthem
• NH, VT, MA, ME
– First Coast Service
• FL
– TriSpan Health Services
• LA, MO, MS
– Noridian – no LCD but a statement
• AK, MN, ND, WA, WY, AZ, Montana
Local Coverage Determinations
• IPF – LCD which include RT/TR as active
• Most LCDs – Inpatient psychiatric/Partial
Hospitalization/Day-treatment Facilities
– Which are many
– Continue to utilize the old language of specifically
mentioning/including Recreational
Therapy/Therapeutic Recreation
IRF – LCD which include RT/TR in
the “3-hour Rule”
• Most state the following
– Provided under an individualized treatment or diagnostic
– Reasonably expected to improve the patient’s condition or for
the purpose of diagnosis; and
– Supervised and evaluated by a physician
• Most state “Recreation is a Non-Covered Service” –
meaning diversional/recreational activates are not a
covered item
• Is not referring to Recreational Therapy
– Which is active treatment – not the provision of recreation
CPT Codes
•97110 – Therapeutic Procedure, each 15 min. therapeutic exercise to develop strength &
endurance, ROM and flexibility
•97112 – Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense,
posture and proprioception
•97530 – Therapeutic activities – direct 1 to 1 patient contact provider (use of dynamic activities
to improve functional performance
•97113 – Aquatic therapy with therapeutic exercise
•97150 – Therapeutic procedure – group (2 or more individuals up to 4 with one TR)
•97532 – Development of cognitive skills to improve attention, memory, problem solving,
•97533 – sensory integrative techniques to enhance sensory processing and promote adaptive
responses to environmental demands
•97535 – Self care/home management training (ADL & compensatory training, meal preparation,
safety procedures, instructions in use of adaptive equipment)
•97537 – Community/work reintegration training (shopping, transportation, money management,
avocational activities and/or work environment/modification analysis, work task analysis
97542 – Wheelchair management/propulsion
Test a CPT Code
Letters From HCFA/CMS to
• “…while specific recognition of recreational therapy is
not given in the instructions, there is nothing that
would preclude the coverage of recreational therapy
when appropriate. Moreover, there is specific language
in the manual which indicates that alternatives to
physical therapy and occupational therapy may be
covered when needed as appropriate.” (Hoyer, 1994)
Letters From HCFA/CMS to
• “…requires inpatient hospital rehabilitation services
may need, on a priority basis, other skilled rehabilitation
modalities such as speech-language pathology services
or prosthetic orthotic services. In such cases, the three
hours a day requirement can be met by a combination
of these other therapeutic services instead of, or in
addition to, physical therapy and/or occupational
therapy. An inpatient stay for rehabilitation care can
also be covered even though the client has a secondary
diagnosis or medical complication that prevents him
from participating in a program consisting of three
hours of therapy a day.” (Hoyer, 1994)
• LMRP = Local Medical Review Policy
• LCD = Local Coverage Determination
ATRA 3-Hour Rule Documents
ATRA is pleased to provide the following documents for the ATRA member(s) to use in advocating for active
treatment recreational therapy services in inpatient rehabilitation settings. For additional information on
interpretation and use of these documents, please contact the ATRA National Office at (703) 683-9420 or the
Coverage and Reimbursement Team Leaders through the contact information on the Team Leadership Directory
Introduction From ATRA Executive Director
8-1-03 Medicare and Recreational Therapy News Release
8-1-03 Excerpt, 42 CFR, Part 412, Page 19: Medicare Program;
Changes to the Inpatient Rehabilitation Facility Prospective Payment
System and Fiscal Year 2004 Rates
04-04-00 HCFA Correspondence
02-18-00 ATRA Legislative Counsel Letter
07-20-94 American Rehabilitation Association Tech Brief
12-23-93 HCFA Correspondence with Enclosure
08-22-89 HCFA PRO Correspondence
08-86 Medicare Hospital Manual Transmittal No. 491
Contact Information
Tim Passmore, Ed.D., CTRS
Assistant Professor
School of Applied Health & Educational
Leisure Studies Program
Oklahoma State University
[email protected]
(405) 744-1811