Home Health & Hospice

One PT Visit with Many OT Visits Can Lead to Trouble

Homecare Insider, August 10, 2009

Yogi Berra once said, “We made too many wrong mistakes.”  That quote applies to one recurring situation in home health care, that being, the provision of several occupational therapy visits after a single physical therapy visit.  Consider this example.
The physician ordered physical and occupational therapy evaluations for a patient after a shoulder replacement.  The physical therapist conducted the initial visit with the OASIS assessment, and reviewed the shoulder exercises with the patient.  The therapist determined that there was an ongoing need for occupational, but not physical, therapy.  The occupational therapist made the second visit, developed a plan for ongoing therapy, and provided eight more visits.  Upon review, the intermediary denied all visits.

What happened?  Occupational therapy cannot qualify a patient for coverage initially but after the patient has had a need for another skilled service, such as physical therapy, occupational therapy can qualify the patient for ongoing care.

In the Prospective Payment System (PPS), there has been a big problem, resulting in many denials, with a single physical therapy visit qualifying the patient for continuing occupational therapy.  The regulation for continuing occupational therapy says the patient must have had a need for physical therapy (or nursing or speech-language pathology services), in the present or previous certification period.  The challenge:  Does one visit demonstrate the need for physical therapy?  The single visit must be reasonable and necessary from a physical therapy standpoint, not to determine whether the patient needs occupational therapy.  

In this case, the patient’s need for physical therapy is very questionable.  The therapist reviewed the shoulder exercises with the patient.  Because the therapist did not feel there was a need for a second visit, chances are the patient knew the exercises and performed them properly.  If so, did the patient really need that physical therapy visit?  This agency’s intermediary said, “No,” and without a need for physical therapy, the patient cannot qualify for continuing occupational therapy.  As a result, all occupational therapy visits were denied.  

Lesson learned:  If the patient really needs physical therapy, then it’s almost certain the physical therapist will need to make two or more visits.  The need for physical therapy can then establish a continuing need for occupational therapy.  

Verify that your agency’s therapists know about the Medicare coverage criteria and other important concerns.  “Therapy Services in the PPS,” a 45-minute interactive CD, can be a resource.