As the population ages, and the majority of older adults express a desire to age in place, the need for home modification evaluations and interventions is expanding. While home modification services are clearly within the scope of occupational therapy, what is not so clear are the options for reimbursement. Many questions arise regarding proper billing.
Medicare-covered clients are entitled, under law, to medically necessary services. Occupational therapy practitioners do NOT have the right, under current statutes, to “opt out” of Medicare. Any occupational therapy practitioner, even those who are not Medicare providers, must directly bill Medicare for any medically necessary skilled therapy services provided to Medicare-covered clients. Whether or not to bill Medicare for home modification OT services must be based on the occupational therapy practitioner’s clinical determination of whether the services are medically necessary.
This guide first provides a brief overview of the occupational therapy practitioner’s role in home modification and the current Medicare program. Second, case scenarios are provided on some of the factors used in determining whether the services are medically necessary. It should be noted that the scenarios are only examples, and each case requires a unique determination. The occupational therapy practitioner is ultimately responsible for determining Medicare medical necessity for each client.