You always want to be sure that what you’re working on with your patients requires truly skilled occupational therapy and also provides them with the best possible outcome.

We also need to ensure our services are skilled and medically necessary; that they require an OT to complete the intervention (we want to avoid a denial at all costs!).

Basically, Medicare states that the interventions we provide must require the “expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently” (Medicare Benefit Policy Manual, Chapter 15, Section 220.3B).

Okay, kind of intense. A way to decide if your interventions follow this rule would be to ask yourself:

Can a CNA or family member do this?

This would apply to a situation where you were in a rush to finish a session and your patient still needed to complete their lower body dressing (no pants-less patients here, please!), and instead of providing lower body dressing retraining, you just put on their shoes and socks for them, even if they can do it themselves with extra time and cues.

That is technically not skilled since you could just call the CNA to finish up since they can do the exact same thing. You want to always be providing education.

If you have a dependent patient, you still need to educate either them, their caregiver or both, as well as have them attempt to assist, even if bed level, if at all possible.

Another question to ask yourself:

Can a personal/fitness trainer do this?

Of course it seems silly to think that a personal trainer at a SNF would be an actual thing, but if you are just doing various upper extremity exercises with no target deficit in mind or just doing the same exercises over and over, that is not skilled.  

Plus, people shouldn’t be working on the same muscle group every day, anyway, for muscle recovery and all that fun stuff.

And I know we all know therapeutic exercise and ADLs are very important, but we have to be crafting our interventions very skillfully (no pun intended).

For example, and this may seem like common sense, but patients need more than just exercise each treatment each day or just ADLs.

You can and should incorporate graded up or down challenges, change (hopefully decrease) your amount of cues, create interventions around the patient’s goals, focus on what deficits hinder the patient from performing what they need and want to do, provide education and more education, and so on.

Keeping it skilled will also include continuously assessing the patient’s performance and modifying as needed, providing ongoing caregiver education if they are present during your sessions, and creating maintenance plans for caregivers to carry out when the patient is discharged from therapy.

I hope this helps, since I know for me it was very confusing, especially starting out and automatically thinking that doing any self care any time was always skilled.

Very surprising to me, at least, to find that that was not the case, so I’m super glad I was eventually informed of the differences.

If you have any questions or thoughts about this, don’t hesitate to leave them in the comments below.

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  • Victoria August 5, 2018   Reply →

    Just starting out (about to begin my 3rd week) I’ve found it difficult to observe physical therapists essentially providing the same skills and therapy. For example, at the facility I work, PTs do a lot of sustained standing tolerance while performing a task…functional fine motor task!

    • Sarah Stromsdorfer, OTR/L August 16, 2018   Reply →

      That can definitely be frustrating for sure. What I like to do is make things as functional as possible, like bring my patients into the kitchen and work on standing tolerance and reaching with dishes, grocery itemsm etc. there. Making things as occupation-based as you can while also speaking with the PTs about the risks duplication of services can hopefully help. Hope this helps!

  • O. Hurdle November 17, 2020   Reply →

    This is more of a question, I am a COTA and I took a call from a patients family member. I completed patients treatment session earlier, so patient was not in my presence. I was told to communicate with family members during treatment sessions, is that skilled?

    • Sarah Stromsdorfer, OTR/L November 19, 2020   Reply →

      I don’t charge for family calls without the patient even though they’re definitely important. It’s tough when it takes up non-billable time but just remember you’re still doing your job and providing value to the family even though it isn’t counted as “productive.” If family/visitors are allowed you could also try to schedule a family education treatment session where your patient can be involved.

  • David March 30, 2021   Reply →

    It seems like so often I ask that same question. I think a lot of the time it seems like we aren’t doing something skilled when we actually are. We aren’t just doing ADLs, IADLs, or therex, we are continually assessing and working toward goals to achieve functional independence outcomes. Good article.

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