Coverage of Therapeutic Recreation in Clinical Settings

1. Coverage of Therapeutic Recreation in Clinical Settings Tim Passmore, Ed.D., CTRS West Virginia Therapeutic Recreation Association Annual Conference Oklahoma State University

2. What is Considered to be Active Treatment by the Center for Medicare & Medicaid Services (CMS)? • Any intervention which • Restores • Remediates • Rehabilitates • Reduces • Eliminates

3. What Settings Require Active Treatment? • Inpatient psychiatric services • Partial hospitalization services • Inpatient Physical Rehabilitation services • Acute care services • Public school systems

4. 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…

5. Recreational TherapyDiversional Activities/Non-Active Treatment • Recreation Activity/Diversional activity • Dominoes • Movie night • Outings • Golf • Etc… • There is therapeutic value • Just not covered by 3rd party Payors • Maintenance and/or Palliative care! • Except in Long-term Care • Hospice

6. 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 Consumers

7. 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 & Medicaid • CMS – makes the rules/regulations

8. 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 • Rehab • Principles/Teachers/Parents

9. Fiscal Intermediary(FI) • Most powerful entity outside of CMS • System is changing • From FI to MAC • Medicare Administrative Contractor (MAC) – Combined management of Part A & B • First contract awarded • Noridian Administrative Services, LLC – Fargo ND • Arizona • Montana • North Dakota • South Dakota • Utah • Wyoming • Noridian Administrative Services – has current statement • Which would include Recreational Therapy • Next MAC contract will manage • Colorado, Oklahoma, New Mexico & Texas

10. 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

11. Administrators • All are concerned with • Generating dollars • Protecting dollars • Complying with regulations • Keeping their job

12. RegulationsInpatient 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

13. 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.”

14. RegulationsInpatient 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 services • Multidisciplinary team • Coordinated care program • Significant practical improvement • Realistic treatment goals & objectives

15. Inpatient Physical Rehabilitation • DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services42 CFR Part 412[CMS-1474-F]RIN 0938-AL95Medicare Program; Changes to the Inpatient Rehabilitation Facility Prospective Payment System and Fiscal Year 2004 RatesPosted 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 CommentComment: 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

16. 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 • Recreation • Diversion • Maintenance • Comfort

17. 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

18. Steps to Obtaining Coverage • Physician’s Orders • Assessment • Goals & Objectives • Treatment Plan • Delivery of Services or Interventions • Documentation of Provision of Services/Interventions • Reevaluation • Discharge Recommendations & Summary

19. Steps to Obtaining Coverage • Follow the Therapeutic Recreation Process • Assessment • Planning • Implementation • Evaluation

20. Formula for Establishing Unit Charges • Salaries & Benefits $2,032,800 • Operational Expense $ 209,440 • Administrative/Clerical Support $ 656,000 • Subtotal $2,898,240 • Overhead @ 40% $1,159,296 • Total Costs $4,057,536 • Cost per hour of patient care: (Divide total cost by number of hours of patient care) • $4,057,536 Total Cost/Year divided by 20,000 Hours of Patient Care/Year = $202.88/Hour • 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.

21. Subject: Systematic Handling of Unit Charges Policy 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. Procedure 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 treatment. 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.

22. Subject: Unit Productivity Policy 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. Procedure 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.

23. Medicare Part A & B • Medicare Part A – has regulatory governance • Inpatient hospitals • Critical access hospitals • Skilled nursing facilities • Some home health • Hospice • Medicare Part B – has regulatory governance • Physicians • Specific medically necessary services • Home health • Outpatient hospital care

24. Prospective Payment System • Based on Diagnostic Related Groups (DRGs) • Payment based on groupings of diagnosis • Adjusted related location within USA

25. Prospective Payment System • Areas • Inpatient Physical Rehabilitation Facilities (IRF - PPS) • Inpatient Psychiatric Facilities (IPF - PPS) • Long-term Care Facilities (LCT - PPS) • DID NOT CHANGE MEDICARE REGULATIONS

26. Local Coverage DeterminationsLCD • 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

27. Local Coverage DeterminationsLCD • IPF – LCD which include RT/TR as active treatment • 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

28. IRF – LCD which include RT/TR in the “3-hour Rule” • Most state the following • Provided under an individualized treatment or diagnostic plan; • 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

29. 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

30. Test a CPT Code • https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp?_requestid=770140

31. Letters From HCFA/CMS to ATRA • “…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)

32. Letters From HCFA/CMS to ATRA • “…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)

33. LMRPs / LCDs • LMRP = Local Medical Review Policy • LCD = Local Coverage Determination

34. 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 http://www.atra-tr.org/teamleader.htm 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 04-04-00HCFA 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

35. Contact Information Tim Passmore, Ed.D., CTRS Assistant Professor School of Applied Health & Educational Psychology Leisure Studies Program Oklahoma State University Tim.passmore@okstate.edu (405) 744-1811