The Importance of Billing Medicare for Home Safety Evaluations.

July 22nd 2024

Occupational therapists play a crucial role in ensuring the safety and independence of seniors in their homes. However, many therapists may not be aware of the importance of billing Medicare for home safety and modification evaluations. This blog post will explore why it’s essential for occupational therapists to understand and comply with Medicare billing requirements for these services.

Occupational therapists cannot opt out of Medicare, and they are subject to the Mandatory Claims Submission regulation. Noncompliance with the Mandatory Claims Submission regulation actually has a $2000 fine per incident. This means that therapists are required to bill Medicare for covered services provided to Medicare beneficiaries (1,2). Home safety evaluations and modifications are considered covered services under Medicare Part B, making it crucial for therapists to understand the billing process. 

So when can I charge cash? 

Not every home modification evaluation and intervention meets the Medicare guidelines for medical necessity.  In 2019 I gave an indepth presentation about home modification assessments being covered by Medicare just before AOTA annual conference. Shortly after, AOTA studied the topic and provided guidelines regarding billing Medicare (3).  Preventative services are not generally covered by Medicare. This applies to an evaluation that is making recommendations for a client who wants to prepare for aging in place.  The client/Medicare beneficiary must be present with the therapist to bill Medicare. Completing an evaluation for a client who is currently receiving rehabilitation services in a skilled nursing facility (SNF) and not able to be present is another cash pay scenario.  Any Medicare beneficiary receiving Medicare Part A services (Home Health, in hospital or SNF) are not covered for Part B services. Review the AOTA article for further details or we cover this in detail in our Certified Home Accessibility Therapist (CHAT) program videos and coaching sessions. 

Benefits of Proper Medicare Billing:

• Ensures compliance with federal regulations
• Provides reimbursement for valuable services to Medicare beneficiaries
• Allows therapists to offer essential services to Medicare beneficiaries without legal complications

Understanding Medicare Coverage for Home Modifications

Medicare Part B covers home modification evaluations when performed by occupational therapists. These evaluations are billed using the appropriate occupational therapy evaluation and treatment CPT codes. It’s important to note that while the evaluation  and occupational therapy intervention is covered, Medicare typically does not cover the cost of the actual home modifications.

Key Points for Therapists:

• Home modification evaluations are billable under Medicare Part B
• Use appropriate occupational therapy evaluation and treatment CPT codes
• Document medical necessity and adhere to Medicare guidelines

Billing Process and Documentation Requirements

To successfully bill Medicare for home safety and modification evaluations, occupational therapists must follow specific procedures and documentation requirements.

Essential Steps:

1. Obtain a doctor’s order for the evaluation or have a provider who will sign your plan of care. 
2. Conduct a thorough occupational profile
3. Use appropriate evaluation codes 
4. Use treatment codes as you are working with the client on trialing solutions
5. Document medical necessity and findings
6. Send your plan of care to the medical provider to be signed 
7. Submit claims using the correct format and coding

It’s crucial to maintain consistent documentation and use a HIPAA-compliant system for storing patient information.

Importance of Continuing Education

Staying up-to-date with Medicare billing requirements and best practices is essential for occupational therapists. Continuing education courses, such as those offered by professional organizations, can provide valuable insights into:

• Medicare guidelines for medical necessity
• Proper use of billing codes
• Documentation requirements
• Strategies for maximizing reimbursement

This is a topic we cover in depth in the Certified Home Accessibility Therapist (CHAT) program. 

Conclusion

Billing Medicare for home safety and modifications evaluations is not just a legal requirement for occupational therapists—it’s an opportunity to provide essential services to seniors while ensuring proper reimbursement. By understanding and complying with Medicare billing regulations, therapists can continue to play a vital role in promoting safety and independence for older adults in their homes.Remember, staying informed about Medicare policies and billing practices is crucial for maintaining a successful and compliant occupational therapy practice. Consider attending workshops or webinars to keep your knowledge current and ensure you’re providing the best possible care to your Medicare patients. The CHAT certification program is definitely a good resource. Find out more details by clicking the CHAT button at the top of the page. 

REFERENCES:

1. CMS (2024) Opt Out of Medicare. Retrieved from: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/manage-your-enrollment#eligibility 

2. US DHHS (2021) Mandatory Claims Submission and its Enforcement. Retrieved from: https://www.hhs.gov/guidance/document/mandatory-claims-submission-and-its-enforcement

3. AOTA  (2024) Payment Policy: Navigating home modifications billing for Medicare-covered clients Retrieved from: https://www.aota.org/practice/practice-essentials/payment-policy/medicare1/navigating-home-modifications-medicare