Occupational Therapy In Health Care, 28(2):209–222, 2014  C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.904960

ARTICLE

Documentation and Reimbursable for Driver Rehabilitation Services Donna Stressel1 & Anne E. Dickerson2 1

Sunnyview Rehabilitation Hospital, Schenectady, NewYork, USA, 2 Department of Occupational Therapy, East Carolina University, Greenville, North Carolina, USA

ABSTRACT. Driving is the method of choice to maintain independent community mobility for most older adults. Therefore, occupational therapy practitioners need to evaluate and provide intervention for driver rehabilitation services. Since reimbursement is often seen as a barrier to providing these services, this paper underscores the value of occupational therapy practitioners providing driver rehabilitation services. Appropriate documentation and guidelines for reimbursement from Medicare are addressed with examples of how occupational therapy driver rehabilitation services can be funded by third party payers. KEYWORDS.

Documentation, Driver rehabilitation, Medicare, Reimbursement

The ability to drive and/or access transportation allows an individual to choose where to live, access needed services, purchase desired goods, and participate in activities that are meaningful and necessary to carry out valued roles in home, work, and community environments. Without the ability to be mobile outside the home environment, individuals may be deprived of equitable opportunities, experience social isolation, and negative effects on their health and well being. Yet driving and community mobility is frequently overlooked or not addressed by occupational therapy practitioners in many practice areas. Although there are reasons for not addressing community mobility and driving specifically, one argument used by therapists is the fact that it is a noncovered or expensive service to provide and in the literature, cost is often cited as a barrier (Betz, in press; Stav et al., 2011). The reality is that occupational therapists have an ethical obligation to identify performance deficits that may affect safety in driving and community mobility with all of their clients (see Slater, this issue). In observation of the obligation to address driving as a means of community mobility, as a meaningful instrumental activity of daily living, important professional and regulatory organizations emphasize and endorse the important role the Address correspondence to: Anne Dickerson, East Carolina University, Greenville, NC 27858, USA (E-mail: [email protected]). (Received 26 February 2014; accepted 12 March 2014)

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occupational therapy practitioner has in addressing driving. For example, the AMA’s Code of Medical Ethics (Opinion 2.24 Impaired drivers and their physicians), it specifically states: Physicians should assess patients’ physical or mental impairments that might adversely affect driving abilities. Later in the statement it specifies occupational therapy: Depending on the patient’s medical condition, a physician may suggest to the patient that he or she seek further treatment, such as substance abuse treatment or occupational therapy (bold added). Additionally, the AMA has a specific CPT procedural code (e.g., 97537 Community/Work Reintegration Training), which specifically lists transportation as a service description. The mission of the National Highway Transportation Safety Administration (NHTSA), a part of the federal Department of Transportation, is to save lives and prevent injuries and economic losses resulting from motor vehicle crashes. As part of their safety program, NHTSA has focused on older drivers with the intent to keep older drivers safe on the road as long as possible. In 2003, NHTSA recognized the importance of occupational therapy and partnered with the American Occupational Therapy Association (AOTA) to develop and fund the Older Driver Initiative (see Schold Davis paper this issue) and other initiatives such as the Gaps and Pathways Project. For the last 10 years, AOTA has promoted driver safety and worked collaboratively with other stakeholder organizations to enhance occupational therapy’s role in driving. Two significant outcomes include CarFit (www.car-fit.org), a collaboration of AARP, AOTA, and the American Automobile Association (AAA) and the second, Older Driver Safety Awareness Week, nationally recognized the first week in December and sponsored by AOTA. Another example is the Hartford Insurance Expertise in Aging (see http://www.thehartford.com/mature-market-excellence/). Their experts in older adults used occupational therapy practitioners to develop the booklets relating to driving, specifically highlighting occupational therapy in Your Road Ahead: A Guide to Comprehensive Driving Evaluations (2013). Finally, the Commission on Accreditation of Rehabilitation Facilities (CARF), who provides accreditation standards for organizations to improve the quality of their services and meet internationally recognized standards, identified the provision of driver rehabilitation services as a unique aspect of care for inpatient rehabilitation programs as well as several specialty outpatient programs. The standards require that a medical rehabilitation program provide or make formal arrangements for several services, depending upon the needs of the persons served and the stated goals of the program. Among the possible services are community integration services, transportation, driver rehabilitation (inpatient rehabilitation, amputation, spinal cord, and stroke specialty programs), and passenger safety (pediatric specialty program) (CARF, 2012 standards manual). Occupational therapists should distinguish themselves as the “go to” profession for driving and community mobility if they want occupational therapy to be recognized by stakeholders as a key profession in the area of driver rehabilitation and community mobility. The profession of occupational therapy is uniquely qualified to provide the services needed to address the issues related to driving. These services include (1) assessing the impact of a medical condition on fitness to drive, (2) providing training in the use of adaptive driving equipment or compensatory strategies, (3) making recommendations for adaptive driving equipment or

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restrictions, and (4) when necessary, assisting in transitioning the person to alternative methods of transportation. VALUE OF ASSESSMENT The automobile is the preferred method of transportation for older adults and for many suburban and rural areas, the personal motor vehicle may be the only means of transportation available. For older adults, driving maintains independence since dependence on specialized transportation services (e.g., wheelchair accessible, door to door service) is far less economic. If an individual with a medical condition can continue to drive with appropriate adaptive equipment and/or compensatory strategies, the cost of a comprehensive driving evaluation by a driver rehabilitation specialist is warranted. Accordingly, comprehensive driving evaluations by qualified professionals (e.g., occupational therapists with specialized training) are appropriate and cost saving for identifying individuals who are unfit to drive. Motor vehicle crashes are the leading cause of injury and death in the United States. In a one-year period, motor vehicle crash-related deaths in the United States resulted in an estimated $41 billion dollars in medical and work loss costs (CDC, 2010). Additionally, motor vehicle crashes are a serious public health issue because of the impact of crashes on the health and well being of all people. When an individual is determined to be unfit to drive because the person poses significant risk to self and others, ultimately both monetary and emotional costs may be saved. The fee for a comprehensive driving evaluation, whether paid by the person or reimbursed by insurance is reasonable compared to the expense of hospitalization for injuries due to a crash. A comprehensive driving evaluation may be the most cost effective method of evaluating driving risk for an individual with medical concerns. Owning and driving a personal vehicle is expensive and all members of society should acknowledge the importance of ensuring that the driver is in good condition as well as the vehicle the person is driving. The value of an comprehensive driving evaluation by an occupational therapist with specialized training in driver rehabilitation should be conveyed to medical professionals, clients, and families. However, the driver rehabilitation specialist must make sure the evaluation is worth the fee that is charged. DOCUMENTATION FOR REIMBURSEMENT The purpose of documentation is to communicate important information about the client, convey the rationale for provision of services and the relationship of those services to client outcomes. Documentation should reflect professional clinical reasoning and expertise of an occupational therapist and the nature of occupational therapy services (AOTA Guidelines for Documentation of Occupational Therapy, 2013). It is imperative that documentation is legible, relevant, and sufficient to justify the services billed. Documentation plays a critical role in explaining the need for therapy services and justification for reimbursement. Occupational therapists need to understand that contract nurses usually review documentation, rather than therapists, and a therapist should not assume that the reviewer would understand why the service requires the skill of an occupational therapist, therefore, the

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documentation should include additional information needed to justify occupational therapy services. The Centers for Medicare and Medicaid Services (CMS, 2013) requires that therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. Medicare administrative contractors (MACs), Medicare carriers, and fiscal intermediaries (FIs) are private companies that contract with CMS to pay bills (see Table 1 for a 2014 list). Carriers and FIs make coverage decisions in their area about what items or services are “reasonable and necessary.” Contractors use Medicare policies in the form of regulations, national coverage determinations (NCDs), coverage provisions in interpretive manuals, and local coverage determinations (LCDs) to apply the provisions of the Social Security Act; that is, to determine whether the service or item is reasonable and necessary. Medicare coverage is based on three main factors: (1) federal and state laws, (2) national coverage decisions made by Medicare about whether something is covered, and (3) local coverage decisions (LCD) made by companies in each state that process claims for Medicare. Contractors develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community. A contractor may develop or revise a LCD, when needed, to assure beneficiary access to care using guidelines for LCD development provided by the Medicare Program Integrity Manual (2013). These companies decide whether something is medically necessary and should be covered in their area. In terms of driving, most LCD’s do not have language that specifically excludes driving and community mobility as a covered service. However, coverage is not guaranteed in such areas even

TABLE 1. The 2014 list of Medicare Part B Contactors (Fiscal Intermediaries) noting that Contractors and LCD Frequently Change. www.medicare.gov Contractor Cahaba Government Benefit Administrators, LLC www.cahabaga.com CGS Administrators, LLC www.cgsmedicare.com First Coast Service Options, Inc. www.fcso.com National Government Services, Inc. www.ngsmedicare.com Noridian Healthcare Solutions www.noridianmedicare.com Novitas Solutions www.novitas-solutions.com

Palmetto GBA www.palmettogba.com Wisconsin Physicians Service Insurance Corporation www.wpsmedicare.com

State(s) Covered Alabama, Georgia, Tennessee

Kentucky, Ohio Florida Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Mexico, New Jersey, Oklahoma, Pennsylvania, Texas, Virginia (counties of Arlington and Fairfax and city of Alexandria) North Carolina, South Carolina, Virginia, West Virginia Indiana, Iowa, Kansas, Michigan, Missouri, Nebraska,

Note: Home Health and Hospice Contractors may be different.

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though the coverage is not specifically listed as a noncovered service. Areas that have excluded driving service have been challenged on appeal and there has been success in overturning these decisions and removing theses exclusions from the LCD. Appendix A has an example of a letter written to a local LCD that, in response to the letter, revised their policies and removed “driving assessments” from the list of noncovered services. Medicare coverage requirements specifically cite the teaching of compensatory techniques to improve the level of independence in activities of daily living as a condition of coverage for occupational therapy. CMS describes the coverage limits of outpatient occupational therapy services under Medicare Part B as follows: Therapy services should be provided in a manner that meets the patient’s needs. The treatment plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. Documentation must be sufficient to demonstrate the specifics of the therapy provided so that it may be determined that the treatment was medically necessary.” (Centers for Medicare and Medicaid Services; Chapter 13) To be considered reasonable and necessary, the services must meet Medicare guidelines for coverage of outpatient therapies, and have basic requirements in common including: (1) A therapy plan of care is developed either by the physician or nurse practitioner, or by the occupational therapist that will provide the occupational therapy services; (2) All services provided are to be specific and effective treatments for the patient’s condition according to accepted standards of medical practice, and the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time; and (3) The services shall be of such a level of complexity or the condition of the patient shall be such that the services required can only be safely and effectively performed by a qualified clinician. In view of the fact that standardized evaluations are lacking, it is essential for practitioners to make the case that his or her evaluation meets these requirements and clearly articulate how the requirements are met in formal documentation. Comprehensive driving evaluations performed by occupational therapists are part of the plan of care that is certified by a physician. The services provided are specific for the patient’s condition according to accepted Standards of Practice (AOTA, 2010) for occupational therapy and are not experimental or investigational. The services for a comprehensive driving evaluation should be at a level of complexity and sophistication that the services required can only be safely and effectively performed by a qualified clinician. Typically service is provided in a setting appropriate to the patient’s condition, and meets but does not exceed the patient’s medical needs. Understanding the guidelines and requirements allows the occupational therapist to clearly address the specific issues and articulate a strong argument for Medicare appeals for service. The therapist needs to state in writing that the comprehensive driving evaluation from an occupational therapist with specialized training is the most efficient way to assess the effects of a medical condition or disability has on driving skills and safety. A thorough assessment in a controlled environment will identify conditions that can be rehabilitated through compensatory strategies or adaptive equipment to allow the individual to resume driving safely.

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Occupational Therapy Reevaluation

Therapeutic Activities: direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes.

Development of Cognitive Skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact by the provider, each 15 minutes. Self Care/Home Management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct on-on-one contact by provider, each 15 minutes. Community/Work Reintegration Training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis) direct one-on-one contact by provider, each 15 minutes

97004

97530

97532

97537

97535

Occupational Therapy Evaluation

Description

97003

CPT CODES

TABLE 2. Medicare Occupational Therapy Codes

This training may be medically necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving or restoring specific community functions which were impaired by an identified illness or injury and when realistically expected outcomes are specified in the plan. This code should be utilized when a patient is trained in the use of assistive technology to assist with mobility.

The patient must have a condition for which self-care/home management training is reasonable and necessary. The training should be focused on a functional limitation(s) in which there is potential for improvement in a functional task that will be meaningful to the patient and the caregiver. The patient must have the capacity and willingness to learn from instructions.

Can only bill this code on first date of contact. Evaluation codes are un-timed, billable as one unit. Not generally reimbursed. Indications for a reevaluation include new clinical findings, or a significant change in the patient’s condition. Reevaluation codes are un-timed, billable as one unit. This procedure involves the use of functional activities to restore functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. Therapeutic procedures attempt to reduce impairments and restore function through the application of clinical skills and/or services. Use of these procedures is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable period of time. They require the skills of the therapist to design the activities to address a specific functional need of the patient and to instruct the patient in their performance. Not generally reimbursed. Coverage for this code is very limited to specific diagnoses and conditions. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and typically are better reported using other codes (such as 97535).

Comments

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In cases where the medical condition or disability prevents safe driving, that individual, family members and/or society will be protected from risk by identifying why the individual is unfit to drive. To support the concept of medical necessity, the practitioners must make a case that driving is a reasonable and necessary activity for an individual to pursue following an injury, illness, or disability from diagnoses. Driving, as a high level IADL, is often a determining factor in whether a person can resume pre-morbid life style and activities. Therefore, the comprehensive driving evaluation is more beneficial to the patient as well as the society than avoiding a decision that allows an unfit person to drive or overly restricts an individual that could return to driving. There are driver rehabilitation specialists who have pursued Medicare requirements and have been successful in documented driving and/or community evaluations as meeting all the requirements for a covered therapy service. Appendix B is an example of a letter of appeal from a therapist that successfully overturned a Medicare denial of payment for driver rehabilitation services. Although other insurance companies follow similar reimbursement guidelines to Medicare, basing decisions on the Current Procedural Terminology (CPT) codes (see Table 2) utilized and medical necessity, there are differences in policies. Facilities and/or consumers should review guidelines to determine what constitutes a covered service and what are reimbursable codes. If all conditions for coverage are met, a program that fails to bill insurance companies to which they have contracts, are not fulfilling their obligations to the clients they serve. It could be argued that failure to pursue insurance reimbursement for covered services, and billing the individual, raises concerns in relation to ethics and fraud.

SUMMARY This paper underscores the value of occupational therapy practitioners providing driver rehabilitation services. In addition to providing appropriate documentation, guidelines for reimbursement from Medicare have been highlighted to illustrate some examples of how occupational therapy driver rehabilitation services can be funded by third party payers. Driving is a critical IADL and practitioners should ethically evaluate and provide intervention and seek the support from appropriate providers. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

ABOUT THE AUTHORS Donna Stressel, OTR/L, CDI, CDRS, Sunnyview Rehabilitation Hospital, 1270 Belmont Ave, Schenectady, N.Y. 12308, USA, [email protected]. Anne E. Dickerson, PhD, OTR, FAOTA, East Carolina University, Occupational Therapy, Greenville, NC 27858, USA. E-mail: [email protected]

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American Medical Association. (2000). AMA code of medical ethics: Opinion 2.24 - impaired drivers and their physicians. Retrieved from http://www.ama-assn.org/ama/pub/physicianresources/medical-ethics/code-medical-ethics/opinion224.page American Occupational Therapy Association. (2010). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 64(Suppl.), S106–S111. Betz, M.E., Dickerson, A.E., Coolman, T., Schold Davis, E., Jones, J., & Schwartz, R. (in press). Driving Rehabilitation Programs for Older Drivers in the United States. Occupational Therapy in Health Care. Carr DB, Schwartzberg JG, Manning L, & Sempek J. (2010). Physician’s Guide to Assessing and Counseling Older Drivers. Washington, DC: National Highway Traffic Safety Administration. Centers for Disease Control and Prevention. (2005). One page fact sheet. Retrieved November 7, 2010 from http://www.cdc.gov/injury/pdfs/cost-MV-a.pdf. Centers for Disease Control and Prevention. (2007). Causes of Death by Age Group. Retrieved November 7, 2010 from http://www.cdc.gov/injury/wisqars/LeadingCauses.html. Centers for Medicare and Medicaid Services. (2013). Chapter 13. Local coverage determinations. In Medicare program integrity manual. Retrieved from http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html Commission on Accreditation of Rehabilitation. (2012). Medical rehabilitation standards manual. Tucson, AZ: CARF International. Dellinger AM, Langlois JA, & Li G. (2002). Fatal crashes among older drivers: Decomposition of rates into contributing factors. American Journal of Epidemiology, 155, 234–241. Galski T, Ehle HT, McDonald MA, & Mackevish J. (2000). Evaluating Fitness to Drive After Cerebral Injury: Basic Issues and Recommendations for Medical and Legal Communities. Journal of Head Trauma Rehabilitation, 15, 895–908. The Hartford Center for Mature Market Excellence. (2013). The Road Ahead: A Guide to Comprehensive Driving Evaluations, Hartford, CT: The Hartford Financial Services Group, Inc. Langford J, & Koppel S. (2006). Epidemiology of older driver crashes - Identifying older driver risk factors and exposure patterns. Transportation Research Part F: Traffic Psychology and Behaviour, 9, 309–321. Lyman S, Ferguson ER, Braver ER, & Williams AF. (2002). Older Driver Involvements in Police Reported Crashes: Trends and Projections. Injury Prevention, 8, 116–120. Marottoli RA, Mendes de Leon CF, Glass TA, Williams CS, Cooney LM, Berkman LF, & Tinetti ME. (1997). Driving cessation and increased depressive symptoms: Prospective evidence from the New Haven EPESE. Journal of American Geriatric Society, 45, 202–206. McGwin G, Chapman V, & Owsley C. (2000). Visual risk factors for driving difficulty among older drivers. Accident Analysis and Prevention, 32, 735–744. National Highway Traffic Safety Administration. (2010). Traffic Safety Facts: 2008 Data. (Report No. DOT HS 811161). Washington, DC. National Safety Council. (2008). Estimating the costs of unintentional injuries. Retrieved November 7, 2010 from http://www.nsc.org/news resources/injury and death statistics/Pages/Estima tingtheCostsofUnintentionalInjuries.aspx Stav, W.B., Snider Weidley, L., & Love, A. (2011). Barriers to developing and sustaining driving and community mobility programs. American Journal of Occupational Therapy, 65, e38–e45.

APPENDIX A Example of Appeal Letter for Non-Covered Services To: National Government Services, Inc. Medical Policy Unit Attention: Name of Appropriate Individual, CPC-LCD Reconsideration Requests

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P.O. Box 7108 Indianapolis, IN 46207–7108 Fax: 717–565–3432 E-mail: [email protected] From: Donna Stressel OTR, CDRS Name and Address of Setting Phone: XXX-XXX-XXXX E-mail: email@address November 2, 2010 LCD Reconsideration Request: Request the language Driving assessments, under Miscellaneous Services (Noncovered), be deleted from LCD ID Number L26884 “Outpatient Physical and Occupational Therapy Services”. To Whom It May Concern: I am an Occupational Therapist and Certified Driver Rehabilitation Specialist employed at Setting of Therapist. We are a provider of services to Medicare recipients in Upstate New York. I am writing to request the language “Driving Assessment”, under Miscellaneous Services (Noncovered), be deleted from LCD ID Number L26884. This request is made for the reason that driving assessments and community mobility services meet all the requirements for a covered therapy service. 1. Medical Necessity—Social Security Act (SSA)1862(a)(1)(A) “No Medicare payments shall be made for expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Safe driving is a reasonable and necessary activity for an individual to pursue following an injury, illness, or disability from diagnoses that support medical necessity (ICD-9 codes that support medical necessity). This high level Instrumental Activity of Daily Living (IADL) is often a determining factor in whether a person can resume pre-morbid activities and live independently. The inability to resume driving often prevents an individual from returning home, accessing needed medical and social services, obtaining food and necessary supplies, and engaging in meaningful activities that promote a good quality of life. The burden of transportation dependence frequently means moving to assistive living communities and/or providing these services by less cost effective means. This activity not only dictates their level of independent living and self worth, but also impacts on their personal well being. Research studies indicate that driving cessation increases social isolation and depression. Driving cessation is among the strongest predictors of increased depressive symptoms even when adjusting for socio-demographic and health-related factors. Depression and depressive symptoms have been linked to functional disability and mortality (Marottoli, 1997). Driving is a serious public health issue because of its potential impact on the health and well being of all people. In cases where an individual continues to drive without the appropriate adaptive equipment and/or compensatory strategies serious consequences often occur. Motor vehicle crashes are the second leading cause of injury deaths among adults 65 years of age and

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older (CDC, 2007) and cost the states and our nation 3 billion dollars annually (CDC, 2005). Statistics on Older Drivers

• In 2008, 13% of the total U.S. resident population (34 million) were age 65 years or older (NHTSA, 2010). • In 2007, there were 31 million older licensed drivers (15% of all licensed drivers) which represented a 19% increase from 1997. Other licensed drivers increased by only 13% in the same time period (NHTSA, 2010) • By 2020, the number of all licensed drivers 65+ will be almost double, yielding more than 76 million older drivers (Dellinger, Langlois, & Li, 2002). • In 2008, 183,000 older individuals sustained traffic crash injuries, accounting for 8% of all the people injured in traffic crashes during the year (NHTSA, 2010). • Compared to other age groups, older drivers are highly susceptible to sustain injuries or fatalities in crashes, mainly due to underlying frailty, medical conditions, and medication use (Langford & Koppell, 2006; McGwin, Chapman, & Owsley, 2000) • By 2030, this group will account for 40% of the expected increase in all crash involvements and for 25% of total driver fatalities (Lyman, Ferguson, Braver, & Williams, 2002). • Beyond loss of function and life, injuries and fatalities contribute to health care and economic costs, for example, • The average economic cost of one non-fatal motor vehicle injury in the U.S. is approximately $63,500 • And for one fatal injury approximately $1,300,000 (National Safety Council, 2008) Driving and Community Mobility Assessments performed by Occupational Therapists are part of the plan of care that is developed and certified by the Physician. The services provided are specific for the patient’s condition according to accepted standards of medical practice. (American Occupational Therapy Association (AOTA) Standards of Practice for Occupational Therapy), and the amount, frequency, and duration of the services is reasonable (1–6 visits). Occupational therapy practitioners (OT’s) have the science-based knowledge to understand progressive conditions and life changes that can affect driving and community mobility. Because OT’s can accurately assess the driving performance or community mobility issues of older adults, they are able to help individuals stay on the road longer and safer by providing strategies for the person, adaptations to the vehicle, or modifications to overcome the complexities of the driving or transportation environments. If driving is no longer an option, OT’s help individuals make a transition from driving to using other forms of transportation. In doing so, OT’s help people maintain their autonomy, independence, sense of worth and community involvement AOTA. Driver Rehabilitation is far removed from driver education or driving instruction provided by driving instructors. Driver instructors/educators teach people the mechanics and rules of driving an automobile (how to drive). They lack the education, experience and most of all expertise to assess individuals with medical

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concerns, and provide the necessary interventions. Individuals in need of driver rehabilitation “know how to drive” the question becomes “should they drive”, and if so are modifications needed to do so safely. The OT is uniquely qualified to assess the impact a medical condition has on driving safety, provide training in the use of adaptive driving equipment or compensatory strategies, make recommendations for adaptive driving equipment or restrictions, and when necessary assist in transitioning to alternative methods of transportation. The OT’s assessment is the safest and most effective way to evaluate driving for an individual with medical concerns. Currently, these services are not reimbursed by National Government Services. Placing the out-of-pocket-burden to pay for such services on the individual is in essence decreasing independent and safe community mobility, and putting society at risk. Without being reimbursed for these services, the older adult faces decreased health care access, is deprived of equitable and just treatment opportunities, may experience social isolation and accompanying negatively effects on their health and well being, places extra demands on all ready burdened caregivers, and eventually contributing to the economic cost of society. According to the Medicare Program Integrity Manual Chapter13, Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is;

• Safe and effective: A driving assessment from an Occupational Therapist with specialized training is the safest way to assess the effects of a medical condition or disability has on driving skills and safety. A thorough assessment in a controlled environment will identify conditions that can be rehabilitated through compensatory strategies or adaptive equipment to allow the individual to resume driving safely. In cases where the medical condition or disability prevents safe driving, Society will not be put at risk by allowing the individual to resume driving without adequate intervention. The OT will be able to address alternative options available to ensure the individual has access to their community and necessary services.

• Not experimental or investigational: Occupational Therapists have routinely addressed driver rehabilitation and community mobility as an instrumental activity of daily living. Driving services performed by an Occupational Therapist meet established criteria of skilled therapy. The services are at a level of complexity and sophistication that the services required can only be safely and effectively performed by a qualified clinician.

• Appropriate: Driver rehabilitation is furnished in accordance with AOTA accepted standard of practice for the diagnosis of treatment of the patient’s condition or to improve the function of a malformed body member. It is furnished in a setting appropriate to the patient’s medical needs and condition, ordered, and furnished by qualified

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personnel, and meets but does not exceed the patient’s medical needs. A driving assessment is more beneficial to the patient as well as the society at large than allowing someone to drive with questionable impairment. 2. “Contractors develop LCD’s by considering medical literature, the advice of medical societies and medical consultants, and comments from the provider community. The contractor should adopt LCD’s that have been developed individually or collaboratively with other contractors. The contractor shall ensure that all LCD’s are consistent with all statutes, rulings, regulations, and national coverage, payment and coding policies.” (Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations) The law requires physicians to provide proper medical care and management for patients, which includes a legal obligation to provide patients in their care with appropriate warning and counseling about possible adverse effects of on treatment. Physicians may be liable for failure to provide proper care in the absence of specific warning about potential adverse effects of treatment on driving or the possible effect of a patient’s medical condition on driving ability. Physicians can be held liable for negligently failing to warn a patient of foreseeable and dangerous consequences of engaging in conduct, e.g., driving that can proximately cause injuries to an innocent third party. Failure to properly evaluate a person’s driving capacity or to determine the adverse effects of a medical condition on real-world driving may raise questions about medical malpractice or negligence. Physicians generally lack the ability to conduct a comprehensive driver evaluation that can include off-road assessment and behind-the-wheel evaluation. Consequently, physicians entrust others, particularly OT’s, to evaluated drivers and integrate clinicians’ findings and recommendations with their own medical knowledge of patients to determine fitness to resume driving (Galski, 2000). The concern for public safety is so great that the American Medical Association (AMA), 2000 guidelines state that physicians have an ethical responsibility to assess patient’s physical and mental impairments that might adversely affect driving abilities. They advocate referring to occupational therapy for comprehensive assessment of driving skills and safety (Drivers, 2010). The AMA is not the only affiliation that recognizes the importance of driver rehabilitation services. The CARF identifies the provision of driver rehabilitation services as a unique aspect of care for inpatient rehabilitation programs as well as several specialty outpatient programs (2008 Medical Rehabilitation Standards Manual). AOTA is working with policymakers, government agencies, and other advocacy groups to address older driver safety and community mobility. AOTA has partnered with the NHTSA to develop and disseminate education modules for occupational therapy practitioners to address the need for more specialized programs to meet the increasing demand. 3. “Contractors shall ensure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment, and coding policies.”

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CPT 97537—Community/Work Reintegration Training: The word transportation is used in conjunction with the words community/work reintegration training, shopping, and other avocational activities. In this context, transportation would suggest a level of independence reached through driving. National Government Services LCD manual identifies this training as being “medically necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving or restoring specific community functions which were impaired by an identified illness or injury and when realistically expected outcomes are specified in the plan. This code should be utilized when a patient is trained in the use of assistive technology to assist with mobility”. Medicare coverage requirement 210.9 specifically sites “the teaching of compensatory techniques to improve the level of independence in the activities of daily living as a condition of coverage for Occupational Therapy. Code 97537 specifically defines transportation as an activity required within community reintegration. Many rural areas in Upstate New York lack public transportation. If driving was not the means of transportation suggested by this code, then what method of transportation should be recommended to patients? I challenge that for these individuals, driving is the sole activity that separates independence in community activities, form total dependence, and a higher burden and cost to society in general. By providing this service to the Medicare population, Medicare allows individuals to resume a level of independence they previously functioned at prior to sustaining a life altering injury or illness. When we look at value, it is understandable that cost is considered within that equation. Again, I argue that the cost of an OT evaluation and two or three subsequent visits to train and teach individuals how to compensate for their physical impairment, is significantly lower than the cost to society for nursing home placement and public assistance programs. Costs associated with subsequent illnesses at a result of being home bound should also be considered. When a determination is made that an individual is not safe in the high level activity of driving, keeping the individual off the road when he or she would have posed significant risk to self and others ultimately saves costs to Medicare and society in the long run. Thank you for your time and consideration in this matter. I will look forward to your response regarding Medicare coverage for this high level activity of daily living. Sincerely, Donna Stressel OTR, CDRS Title It is important to note that on February 12, 2011, Ms. Stressel received a letter from National Government Services, Inc. indicating they were going to revise the LCD to remove the driving assessment from the excluded services. National Government Services did note that “such assessment must be related to the presence of or recovery from a specified illness or injury and be expected to result in an occupational therapy plan of care for restoring or significantly improving functions necessary for the safe operation of a motor vehicle.”

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Stressel and Dickerson APPENDIX B

Individual Appeal Letter for Denial of Payment To Whom It May Concern: Re: Provider NPI: XXXXXX HIC: XXXXXXX Services Provided To: Medicare denies payment as stated: “This claim was denied after review and it was determined that the documentation did not support medical necessity. Not covered for generalized aging. LCD L26884” Appeal: John Doe was evaluated for driving ability because of arthritis in his bilateral lower extremities which causes increased reaction time (ability to move foot between gas and brake), and a retinal vein occlusion in his right eye which causes blindness in that eye. Occupational Therapists (OT) are uniquely qualified to provide these services due to their extensive educational background and experience with activities of daily living (ADL). OT curricula includes instrumental activities of daily living (IADL) which refers to tasks beyond caring for oneself, that involve interaction with the physical and social environment. Driver rehabilitation services (driver evaluation, driver retraining and adaptive equipment recommendation) is a highly specialized area of practice for occupational therapists, and is not analogous with driver education/instruction through traditional driving schools. Driver rehabilitation services are for individuals with disabilities and/or medical conditions that may prevent or put an individual at risk while driving an automobile. Please refer to the attached: Dr. John Smith’s prescription for this service. A summary letter dated February 17, 2012, an On-The Road (Functional) Evaluation, Community Mobility Assessment, and Community Mobility Recommendations. All provided by Donna Stressel, OTR, CDRS. In addition, please see the Doctor’s certification of the assessment and plan of care. These records demonstrate the Doctor’s involvement. Also, I am including copies of Ms. Stressel’s Occupational Therapist license and Certified Driver Rehabilitation Specialist certificate. Very importantly please see the two publications and references regarding the OT role in Driving Assessments. Thank you for your time and consideration. If you would like to discuss this appeal I can be reached directly at my office (XXX) XXX-XXXX. Thank you very much,

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