I recently had a Medicare appeals clerk rev-iew a denied occupational therapy claim. The therapist stated that she had the patient participate in "tabletop" activities to improve the patient's functional performance with ADL. Although we probably could understand her terminology, the Medicare clerk was unable to.
When we are working with patients at the sitting level, there are three things that I think we should consider: Is the person at sitting level for at least 50 percent of all activities of daily living? Is the patient able to communicate basic needs of comfort, pain or distress? Are there any adaptations needed to ensure proper positioning and body alignment?
To merely roll a client up to a table without considering the above demonstrates poor clinical judgment. If you tell Medicare you are doing "table top activities" and there is no clear functional purpose, it may deny the claim. You must use technical jargon to justify what you do. Gradation of an activity can typically be accomplished by either sitting or standing. This supports my rationale for ongoing review of your patient's treatment plan, goals and objectives. Updating them lets one know that you are attentive to the details of your patient's case and care.
Unfortunately, I have found that poor documentation and lazy clinical hands-on practices are usually synonomous. On the other hand, just because your claim is denied doesn't mean that you are not a good clinician. I know many excellent clinicians who get denials, but they usually have excellent initial evaluation and progress notes to back up the claim. Developing functional activities appropriate to your patient means careful consideration for the chairbound person. Before you begin a treatment session, ask yourself:
Can I recall the purpose of this task? What is the patient's goal?
Will this group activity build the patient's self esteem or lower it?
Will this task immediately connect to a functional task?
Are elbow and table height appropriately aligned?
Are personal glasses needed for this activity? Is there glare in the room? Is the room too dark? Is the client neatly dressed, with hair combed?
Do I need to adjust the seat?
Are his or her feet on the floor, pedals or both?
Are all wheelchair safety measures intact?
What upper- and lower-body muscle groups will be involved in this activity?
What head and torso control will be needed?
How long will this activity last, and at what point will I adapt it?
Can this person stand for intervals, stretch and shift his own weight?
If stringing beads will improve the patient's ability to button clothes, then try it. But why not use real buttons on a shirt or blouse to practice this? I have found that simulating the activity as close as possible to the real thing works for me. The older-adult age group wants purpose, and they need to know how they are going to benefit from tasks.
Functional performance table activities can begin with some of the following:
gardening or horticulture to improve upper-body performance & mood;
bilateral cooking and meal preparation at sitting level;
hand and upper-body exercises before fatigue or joint ache begins;
hair/make-up sessions and shaving safety;
reading gadgets and devices for artistic expression;
writing letters, making holiday cards, or sewing own clothing;
practicing basic computer skills (write a letter on a computer);
simulating joint protection techniques with equipment on table devices (door knobs, clothing, tying shoes, propelling wheelchair);
practicing wheelchair safety while sitting and standing;
doing group exercises with and without resistance, with music; and
forming a band, using instruments to work on muscle groups
You would document this in a technical way. For example: "Mrs. Jones participated in therapeutic strengthening of bilateral wrist extensor in full range. Last week she was at a muscle grade of 'poor plus,' with two breaks per session. This week (date), she is able to functionally reach into her closet to safely obtain items from the closet at wheelchair level."
Be creative in tabletop activities. If you are bored, chances are your patient is, too. If you cannot afford to buy simulated equipment, make up your own. I try not to repeat the same task every day with the same patient, but in many cases repetition has its place. Our backgrounds have prepared us to think about the patient's psychosocial, emotional and physical needs. Growth sometimes means trying something new.
Clarissa Smith, PhD, OTR/L, has a doctorate in health services administration with a specialty in gerontology/geriatrics. She is currently an independent contractor, trainer, consultant and workshop leader in geriatric rehabilitation. Readers may contact her at (205) 798-2963, or by e-mail at firstname.lastname@example.org.
Medicare Reverses Alzheimer Policy
Years of discrimination against patients diagnosed with Alzheimer's disease should come to an end gradually as carriers and intermediaries abide by a new rule sent down late last year by the Centers for Medicare and Medicaid Services (CMS). The change also should give occupational therapists more opportunity to evaluate and treat patients in the early stages of the disease.
Up until now, some Medicare carriers and intermediaries automatically "edited" out any medical claims from patients whose primary diagnosis was Alzheimer's because the disease is incurable, even though the same conditions are covered in patients without Alzheimer's.
But advocacy by the Alzheimer's Association Medicare Project has convinced CMS that Alzheimer patients do benefit functionally from rehabilitation at most stages of the disease, and carriers will be instructed to cover evaluation and reasonably necessary treatment. CMS is instructing providers to submit primary and secondary diagnosis codes that "most closely fit the medical problem" in Alzheimer's patients being treated for specific conditions.