What is Skilled Occupational Therapy?

Have you documented this phrase before? “Patient would benefit from skilled occupational therapy services.”

Have you ever stopped to think about what it is you’re saying? What does “skilled” even mean? Why is this phrase important? And more importantly, what does “skilled” mean for how occupational therapy practitioners are paid for their services?

Podcast: Ep 22. Everything You Need to Know about Skilled OT Services

What is considered skilled occupational therapy?

Skilled occupational therapy services typically means that the services provided requires the training and experience of an occupational therapist or occupational therapy assistant. Good news is Medicare has a standard definition for to help us start the conversation about the value of our “skilled” services. Here’s how Medicare defines “skilled”:

“The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional”

Medicare Benefit Policy Manual, Chapter 15 (Rev. 11771, 12-30-22), page 184 – bold added for emphasis

Let’s break that down.

This definition of skilled services applies to OTs, OTAs, PTs, PTAs, SLPs. It is not to say that someone doing work labeled “unskilled”, such as services provided by techs or nursing assistants, are not valuable or don’t require training, it simply means they don’t meet the definition of a “skilled service” under Medicare.

That’s why you will also hear a delineation between “nursing” and “skilled nursing” when we talk about reimbursement.

Occupational therapy services are considered skilled because of the extensive training we go through to develop our clinical decision-making.

However, just because you are a skilled provider doesn’t automatically mean everything you do is considered “skilled”.

Are all skilled occupational therapy services covered by Medicare?

When we think about a skilled service if often comes down to whether or not we can bill for our services. We use that phrase “Patient would continue to benefit from skilled OT,” as a way to justify coverage of the care provided.

However, just because an intervention or evaluation may be skilled, such as driving rehab or home modifications, does not mean Medicare covers those services. In fact, many skilled services that occupational therapy practitioners provide that are not always covered by Medicare.

Some of this lack of coverage is because under the conditions of coverage, Medicare requires therapy services check three boxes.

Therapy services must be:

• skilled
• reasonable
• and necessary

So, although a service may be “skilled” it may not also be reasonable and necessary. Additionally, some services are simply not approved for coverage under Medicare. Another prime example would be telehealth. Many clinicians can provide skilled services under telehealth, and those services are often reasonable and necessary. However, until recently, Medicare didn’t allow therapy practitioners to provide telehealth and be reimbursed.

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What are examples of skilled OT services?

Just because a services is skilled for one patient, doesn’t mean it will be skilled for another. Here are some questions to ask yourself to help determine if your service is skilled:

• Could this intervention be performed by someone else without my training safely and effectively?
• Did this intervention require modifications based on the patient’s condition?
• Could this intervention be taught to someone else?

It’s important when asking ourselves this question to ask them with a skeptics view. Asking ourselves this question can help us think critically about whether or not our services are value, if they are reimbursement, and also helps us know how to explain our skill to others.

Are Home Exercise Programs a Skilled Service?

A common area where practitioners start to venture into unskilled areas is with a home exercise program. So, let’s review a couple of scenarios:

Patient A: Patient A recently had an shoulder replacement has a prescribed precautions from their surgeon. The OT evaluates the patient and develops a custom home exercise program that complies with the patient’s precautions. The therapist provides education on how to safely perform the program and helps the patient practice the program while providing feedback.

Patient B: Patient B had surgery a few months ago and got a home exercise program two weeks ago. The patient received education previously on how to progress their program and understands how to complete their program. The OT continues seeing the patient because they haven’t yet achieved optimal outcomes.

Do you think both of these are examples of skilled services? If not, which one would you say is not an example of skilled service.

So what DOES it mean to provide skilled occupational therapy?

Just because it is obvious to you… doesn’t mean it is obvious to someone else without your skill!

Sometimes, clinicians think that because something is obvious to them, it would be obvious to someone else. This is because we get so used to doing things a certain way (providing cues for safety, setting up the environment to facilitate participation) that we start to forget just how much knowledge is going into that intervention.

Here’s another way I challenge you to think about skill: Would a stranger off the street do exactly what you did, with the exact same intention, and with the exact same environmental setup as you? Would they provide the same cues? Would they use their observations to adjust the environment or the way they performed a task?

Even other skilled clinicians don’t have the same training that we do. They don’t think about situations the same way we do because they don’t have our training. They are experts in their domain and we’re experts in ours. You should be proud of the skill you bring to the table! Describing your skill is important for defending the importance of your services and should be paid for.

Providing appropriate education and intervention is also part of demonstrating our competency. Occupational therapy practitioners often tailor their sessions to meet that patient’s needs and provide them with the just right challenge. So just because an intervention seems obvious or ‘easy’ to you, doesn’t mean it isn’t skilled!

There’s so much more to say on this topic so listen to the podcast for more examples (this is also a hot topic we discuss in the Amplify OT Membership)

Is it important to document skilled OT services?

Knowing you are a skilled provider and that you’ve provided a skilled service are only part of the picture. It is also your responsibility to accurately document it.

Good news is Medicare provides us with some guidance here as well.

“A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period. In addition, a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.

Medicare Benefit Policy Manual, Chapter 15 (Rev. 11771, 12-30-22), Page 192 – Bold added for emphasis

Document skills is important for reimbursement, reporting what happened in the session, and communicating patient progress or medical condition. Being able to document your skill translates into your advocacy for OT services and why you should get paid.

AOTA has has some really fantastic documentation resources which I’ve linked for you at the bottom of this article.

Your documentation must clearly show how you as the therapy practitioner implemented your skill throughout the session.

Think back to OT school and all of the activity analysis assignments we did. Stuff that used to seem impossible, but as you’ve gained experience, it’s second nature.

It’s important to remember that document your skill doesn’t have to take a ton of time. Work smarter, not harder. Documentation just like anything else is a skill that takes though and practice. Using the WHEW method and Medicare guidelines can help to make sure you cover your bases.

Does all of this have your head spinning a bit? 😵‍💫

It’s totally okay if some of this makes you head spin a smidge. That’s normal when you’re thinking hard about a topic. But if there is one thing you should take away is that you have magic in what you do every single day.

Occupational therapy is a highly skilled profession, so much so that Medicare outlines what makes us unique. It is our responsibility as a profession to demonstrate, communicate, utilize, and document how we use our vast clinical knowledge and intention to create meaningful changes.

Understanding why what we do is unique and skilled is critical in advocating for our profession. While it would be ideal for everyone to automatically know what we do and why OT is amazing, its part of our professional responsibility to spread the word and advocate for our services.

If you’re looking for some mentorship or a guide in this area, I encourage you to check out the Amplify OT Membership which is full of wonderful practitioner and students, courses, and access to me!

To get you started right now, I put together a free OT podcast playlist. Use the playlist to enhance your confidence and save some time! Just use the form below and it’ll get sent directly to your inbox.

Resources

• CMS: Medicare Benefit Policy Manual, Chapter 15
• CMS: Outpatient Therapy Coverage
• Amplify OT: How To Bill Occupational Therapy Under Medicare Part B
• Amplify OT: How to Apply the Medicare 8-Minute Rule in OT Billing
• Amplify OT: Reimbursement Models in OT: Do You Know What They Are?
• Occupational Therapy Medicare and Policy Membership
• The Amplify OT Podcast
• AOTA Documentation Page (Including their documentation CEU series)
• AOTA: WHEW an Effective and Efficient Note-Writing Technique
• AOTA: Guideline for Documentation of Occupational Therapy
• AOTA: Documentation Q&A

Special thanks to Lindsay Bright, OTD/S for her contributions to this article!