REIMBURSEMENT FOR LEISURE AS A
THERAPEUTIC MODALITY
PATIENT DRIVEN PAYMENT MODEL
As of October 1, 2019, the Patient Driven Payment Model is the new classification system for Medicare Part A patients in SNFs (CMS, 2019). The CMS (2019) has transitioned to this new model so that reimbursement is primarily based on a person’s unique characteristics, rather than the volume of services they receive.
The following are some of the basic differences between the older model, RUG-IV, and the new model, the PDPM:
RUG-IV
Patients are placed in payment groups primarily based on the volume of therapy services they receive
PDPM
Patients are classified into payment groups based on individual characteristics, needs, and goals
RUG-IV
OT, PT, and SLP services were bundled for payment classification
PDPM
OT, PT, and SLP are all separate case-mix components
RUG-IV
Higher levels of dependence meant higher levels of payment
PDPM
Higher levels of dependence do NOT mean higher levels of payment
RUG-IV
Group therapy was limited to 25% of a person’s treatment time and there was no limit on concurrent therapy
PDPM
Combined limit of 25% for both group and concurrent therapies per discipline
Intended Benefits of PDPM:
- Improved payment accuracy -
- Focus on client-centered care -
- Streamlined assessment schedule -
BILLING CODES
The following are examples of CPT codes OT practitioners can bill to be reimbursed for leisure as a therapeutic modality. It is important to note that leisure itself is not the goal, but rather a modality used to reach a therapeutic goal.
CPT CODE 97535: SELF-CARE/HOME MANAGEMENT
Leisure as a therapeutic modality can be used to establish or restore an individual's ability to complete self-care or home management tasks.
Example: A resident who enjoys baking, knitting, and mahjong would like to get back to doing self-care and home care tasks. The OT practitioner takes those interests into consideration and collaborates with the resident to decide upon a baking task. During this OT session, leisurely baking will be a modality to restore the resident's abilities that enable her to function with as much independence as possible. The resident's enhanced abilities will decrease the level of support she requires and increase her feelings of self-efficacy.
CPT CODE 97112: NEUROMUSCULAR REEDUCATION
Leisure can be used as a therapeutic modality to facilitate movements for neuromuscular reeducation. Anytime that you are engaging the nervous system to elicit a response of the muscular system you are using neuromuscular reeducation. In this case, you would be using leisure to engage the nervous center to elicit a response from the muscular system.
Frames of references/theories that you can use to guide therapy when using this code:
Motor Learning theory (Case-Smith & Exner, 2015; Sabari, Capasso, & Feld-Glazman, 2014)
Neurodevelopmental approach (NDT; Sabari et al., 2014)
Proprioceptive Neuromuscular Facilitation (PNF; Sabari et al., 2014)
Example: The OT practitioner finds out through a resident's leisure profile that the client enjoys woodworking. The client's goal is to regain movement after a stroke. The OT practitioner sets up a woodworking station for the resident. The resident sands and hammers as a modality to engage the nervous system while engaging in a meaningful activity. This enhances repetition, duration, intensity, and task-specificity associated with motor learning.
CPT CODE 97140: MANUAL THERAPY
Leisure can be used as a modality to encourage movement, which is assisted by therapist. The OT practitioners can use leisure activities that the individuals enjoy to make the therapy meaningful for the client. Also, the client is more motivated to engage in the session when engaged in meaningful occupations which can encourage participation and well as outcomes of the therapy. OT practitioners can use leisure as a therapeutic modality when using tissue mobilization, joint mobilizations, and massage.
Example: A resident recently had a stroke and is experiencing weakness and limited ROM in the right upper extremity. This person was a homemaker and enjoyed hanging laundry outside. The resident and OT practitioner go outside for a laundry activity. While the resident hangs up laundry, the OT practitioner facilitates active assisted range of motion (AAROM) while approximating the head of the humerus into the glenohumeral fossa to compensate for weak rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis).
CPT CODE 97129: COGNITIVE FUNCTION INTERVENTION
CPT Code 97129 is a new billing code for cognitive function. It is for billing therapeutic interventions that focus on, "cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact" (AOTA, 2019c, CMS, 2020). This code is to replace codes G0515 and 97127, which have been removed from HCPCS and CPT manuals as of January, 2020 (AOTA, 2019c; CMS, 2020).
Example: beading specific patterns, crocheting, puzzles, baking, gardening, loom, musical instruments, dancing.
These types of leisure-based activities stimulate cognitive function in the following areas: executive function, sequencing, working memory, etc. (use words from OTPF).
CPT CODE 97110: THERAPEUTIC EXERCISE
OT practitioners can incorporate leisure activities to stimulate motion and to facilitate range of motion (ROM). Leisure used to facilitate therapeutic exercise activities that are meaningful to residents can have significant benefits (Grönstedt et al., 2013). Grönstedt et al. (2013) asserted that individualized, client-centered exercise activities have better outcomes than general exercise programs. Using leisure as a therapeutic modality would facilitate these positive outcomes and motivate residents to be active.
*Note: OT practitioners should NOT bill therapeutic exercise alone because they should not be doing rote exercise by itself. It is unethical for OT practitioners to do rote therapeutic exercise that is not meaningful to the client. It is appropriate to use 97110 if the resident is doing an occupation-based therapeutic activity that facilitates strength and ROM.
Example: A resident who was a homemaker is experiencing generalized weakness. The resident goes outside and hangs laundry on a line. The therapist uses a gait belt and stand-by assist to ensure safety. As the resident regains strength, the therapist will grade the activity by including heavier pieces of laundry to hang and eventually providing wrist weights. This OT session can and should also be billed under Neuromuscular Re-Education (97112) since hanging the laundry is facilitating repetition, duration, and intensity in a meaningful way.
CPT CODE 97530: THERAPEUTIC ACTIVITY
Leisure can be used as a modality to foster therapeutic activities to improve cognitive and performance skills. However, it is important that OT practitioners are mindful with how they are using therapeutic activities as Lamb (2017) asserted there is an overuse of therapeutic activities in SNFs.
*Note: OT practitioners are encouraged to use this code with other codes, such as Neuromuscular Re-Education (97112).
Example: A resident stands with support at a standing loom and uses both hands to weave a design. The following performance skills are addressed: standing endurance, dynamic standing balance, bilateral hand use, upper extremity endurance, fine motor dexterity, sequencing, and other cognitive skills.
APPEAL LETTER
The word “leisure” may be seen as a red flag for Medicare reviewers, even if it not the goal of therapy. It is important to note that leisure is reimbursable when used as a modality and not as a goal. In addition, some Medicare reviewers may deny reimbursement for the CPT codes described above. In the case of a payment denial, the OT practitioner will need to write an appeal letter to provide clarification and to justify the need for this type of intervention.
It is important to appeal payment denials and advocate for the role of OT in billing these CPT codes. We have presented evidence that indicates the many benefits of using occupation-based interventions, and these codes can accurately portray skilled OT services.
APPEAL LETTER EXAMPLE
This is an example appeal letter from a case scenario in Mayasich, Tyce, and Janssen (2019).
This includes justification of services for CPT codes 97530 (Therapeutic Activity) and 97535 (Self-Care/Home Management Training). This template is meant to serve as a starting point for writing an appeal letter, and should be tailored for each unique denial of payment.