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Important information about why your OT is eyebrow deep in paperwork

How would you like to wake up one morning and find out that there are new rules you need to know in order to get your paycheck at the end of the week?  Those of us who work in private practice understand that the rules for reimbursement change and shift constantly, but imagine wading through hundreds of pages in the hopes of trying to find the tidbits that actually apply to what you are supposed to be doing.  Enjoy this link for some light reading: Medicare Physician Fee Schedule Final Rule CY 2013 .  These requirements were just recently published and significantly change the coding requirements for Medicare reimbursement.  Again.

Other changes that we have this week are more wonderful rules to contend with - this time having to do with complex requirements for what a physician's referral has to say in order for a school district to bill related services under the Medicaid program.  This NYS Medicaid rule set is not as long as the CMS rules but only covers a very small component …

Who co-opted my interventions???

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This will be a brief entry to serve as placemarker for a larger discussion, if it ends up being warranted.  I have blogged before about my basic understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings.  Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. As Bruner has pointed out, words reflect our beliefs that frame our narratives and support our culture.

Today I was being interviewed by a media person and they were confused about my use of the word 'intervention'  when I was talking about 'occupational therapy interventions.'  This was surprising to me.  My message to them was focused on the friendly context of my clinic and the services we offer, and their understanding of the word 'intervention' was related to a reality …

The most important part of occupational therapy assessment

This morning my OCC 471 class is taking their final examination as I write this entry.  The class content was focused on occupational therapy assessment in pediatric settings and I am aware that the students are nervous as I sit at the front of the room.  I wish that I had a way to make them feel better.

This blog is generally about my practice and not about my teaching - even though there are many logical points of intersection.  The whole point of teaching is to prepare people FOR practice and I know that all these students spent the weekend trying to answer the same question, "How will I know when I know enough??"

As I was walking toward the college this morning I watched birds flying around the bell tower of Ball Hall.  My immediate thoughts were related to wondering why birds choose the highest spot on campus to congregate.  I figured that there were probably a few possibilities:

the like the view of the lakethe perch has geographic proximity to nestingtheir leader went …

Environmental sustainability and occupational therapy practice

I like ideas.  I even like big ideas.  That would include big ideas that are created simply for academic purposes.  However, as my bio indicates, I am a pragmatic guy who is sometimes at odds with his transcendent training.  Or something like that.

So in other words, I thought I liked ideas.  Maybe sometimes I don't.  I am starting to wonder.

The latest barrage of ideas that I got hit with this week has to do with sustainability and its application to occupational therapy.  I have some opinions about this that are probably a logical extension of these ideas that I blogged about in 2009 that relate to developing lexicon related to social or occupational justice constructs.  Please go read that information first if this is a topic that interests you.

OK so this week I saw a student spam posting the OT Connections site trying to get people to answer some survey about the role of occupational therapy with sustainability.  I normally just ignore spam posting but I went to the survey an…

Letter to a prospective occupational therapy student

I think program directors and faculty can tune in to this as well so they are more aware of what goes on...

Dear Prospective Occupational Therapy Student:

Thank you for contacting me and asking about volunteer opportunities at my facility.  As a part-time occupational therapy educator I understand that most programs have some component of volunteerism associated with application to a program.

I had to complete a similar level of volunteer experience when I applied to my occupational therapy program as well, and I fondly remember my volunteer experiences.  I began those experiences a full year prior to submitting my application, probably because I read the admission requirements and saw that it was something valuable that would help me begin to make choices about a possible occupational therapy career.

My first volunteer experience was exciting and frightening.  I assisted in a crafts group that was run at a long-term institutional setting for veterans who had severe mental health diff…

Health insurance policy and indirect methodologies for cost control

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Last week the Centers for Medicare and Medicaid Services (CMS) released the final rule for the 2013 Home Health Prospective Payment System. The rule includes rate reductions as well as complex new requirements for re-assessment and coding.

It is only a 298 page document that requires accountants, lawyers, and politicians to interpret but don't worry.

It has been interesting in the last week to read email and press releases from therapy staffing agencies who are struggling to process the changes associated with the new CMS rules in addition to the realities of aspects of the Affordable Care Act which has impact on health benefits they need to offer to their own employees.  These staffing agencies took a double hit this past week so if you know anyone who owns one of these agencies or functions as a manager of these services I strongly suggest you offer them Advil, a shoulder to cry on, or perhaps a long vacation.

Normally I am not a big fan of 'travel' therapy or temporar…

More on proprioception

A couple posts back I blogged about a new tool that has been in development called the Comprehensive Observations of Proprioception.  I was a little surprised about the editorial decision to publish an article about performance on the tool without publishing about the tool itself.  Now we have a paper on the tool itself - so the ordering of publication is a question for AJOT editors - not the authors of the paper.

The authors describe the tool as an observational measure that is criterion referenced.  The test includes 18 items that purportedly represent some aspects of proprioceptive function and they use literature review as one tool to substantiate the content validity of the items.  As I mentioned in the original post on this matter I am concerned that some of these items might represent some aspect or measure of proprioception but then again they also might not.  Fully 25%+ of the items are behavioral measures like 'overactive' and 'enjoyment when being pulled' …

Support regulations to remove potential conflicts of interest in the New York State Early Intervention Program

More regulatory mumbo-jumbo, while I am on a roll:

The New York State Department of Health has proposed an amendment to Subpart 69-4 of Title 10 of the New York Codes, Rules and Regulations, the Early Intervention Program. The public comment period ends October 22, 2012.  The new regulations create a requirement for arms-length relationships to tamp down conflict of interest that may be contributing to over-utilization and cost over runs.

An arms-length requirement between evaluators and providers is reasonable given the evidence of inappropriate utilization and significant cost over runs in these programs.  Although not all inappropriate utilization can be attributed to this factor, it is ethically correct for providers to remove any possibilities of conflicts.  Existing rules and regulations, whether in professional practice acts or the EI regs themselves, have not controlled this problem

Here is a pertinent part of the regulation:

 (ii)(a) For children referred to the ear…

Different perspectives on concerns with CPSE services in NYC

The following material was copied from the NYSOTA Facebook page.  A fan of the page (George Nickel) posted a general "calling out" to NYSOTA which prompted my response.  This might be lengthy, but I believe that it is instructive.


Post from George Nickel on Facebook:


Okay, I am calling you out. We have received written support from The New York State Speech Hearing and Language Association and the Regional Physical Therapy Association but none from the OT regarding the issue of the Related Services Tier System of The NYC Department of Education. Is it not an important issue that children with special needs and their families need you to join with the other organizations to advocate for not just them but for your profession?

Christopher Alterio responds:

George, this sounds like a local RFP that you lost and not a professional problem. if you have some more detailed information to share I would be interested in seeing it. I looked at various Facebook pages that are linked of…

On piano tops and proprioception

OK so I haven't let my inner R. Buckminster Fuller out for a walk lately so I think it is time to address a problem that I perceive with some aspects of clinical problem solving in occupational therapy.

Here is some background first:

In this month's AJOT there is an article on Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities (Blanche, Reinoso, Chang, & Bodison, 2012).  It is an interesting article that demonstrates differences in test performance on an observational measure of proprioception between children who have disabilities and their typically developing peers.

The authors correctly point out that we only have limited means to actually measure proprioception.  The Standing and Walking Balance subtest of the SIPT is a good measure, but like other measures of balance it is confounded by proprioceptive processing, labyrinthine righting, and optical righting.  It is difficult to really know how much propr…

When it is not in your job description...

Well I am sleeping better tonight knowing that the Chicago teacher strike is over!!!  All of the really important things like making sure raises stayed in place and health care contributions stayed low got the immediate attention they required.  Muscling out charter schools got a lot of good attention also and of course that is good because we don't want to have competition against a failed school system.  The less important issues like teacher evaluation systems got pushed off into the future.

I don't even live near Chicago and I have no skin in that game directly but I just wanted to express how happy I was that those Union efforts will continue to work in favor of students - just like I saw them working in my own community recently.

You see there was a four year old child who has a physical disability - doesn't even matter what the disability is exactly so I will leave that detail out - and he was happy and excited to start his school year.  All summer long his COTA wor…

More discussion re: the AAP Policy Statement on sensory integration

This was written in response to Dr. Clark's letter to Pediatrics regarding the AAP Policy Statement:Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.  

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Dr. Clark's response included some important points which were good to read, including recognition that single modality interventions tend to be ineffective; I am hopeful that her statements will help to move occupational therapy practice away from these interventions.

I was also glad to see mention of the neurobiological literature as theoretical backing for some interventions.  This is important literature that we should all keep in mind when trying to understand apparent processing difficulties.

Finally I was glad to see mention that occupational therapists use a wide variety of interventions with sensory processing interventions among them but not representing them solely.  I think we need to remind or medical colleagues of this fact lest we become associated w…

How to solve children's complex feeding difficulties.

Physics tells us that energy and mass can't be created or destroyed; rather they are transformed from one form to another, at least in closed systems.  My brain can't handle much past Minkowski space so I get a little fuzzy if I try to understand conservation principles in expanding space-time volumes, but then again I am no physicist and I am certainly no mathematician.

I've been thinking a lot lately about energy and where it goes when variables are introduced into a system.  A parent began presenting me with a complex pathway of what-if scenarios regarding her child's eating skills - what would happen if this occurred, and what would happen if that occurred - and she had the entire child's trajectory imagined before a single bite of food made it past the child's lips.  There was no pause along the trajectory to map out the potential energy within the system (that might subsequently be transformed to a different kinetic pathway) because the parent already had…

I have no title for this

I was reading the Medscape Oncology pages today.  I received an email notification about a series of articles on palliative care and most of them were quite good.  There was a particularly interesting perspective on DNR choices and showing patients (who have terminal disease) CPR videos and how this impacted their choices for end of life care.

I started thinking that this was good information.  Then I started thinking that it is information that could be bureaucratically abused.  It worries me when I start seeing people use the word 'economics' next to 'end of life care.'  I think if we focus on quality issues and as long as we are honestly looking at quality issues then it is all ok.

Anyway, I started clicking around and then I stumbled across an older article and video about how doctors need to understand the needs of care providers.    I thought that it was a kind message and in watching the video portion I was thinking that Dr. Marshall seemed like a very kind doc…

I believe that small things matter

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I've been reflecting today on my belief that small things matter.

This first came to mind when our current OT student intern jokingly commented that we almost lost another puzzle piece - which is justification for disaster alert at ABC Therapeutics because I kind of have an unhealthy obsession a value for keeping puzzles complete... We recently had a celebration when we finally found the beloved monkey that was missing from a puzzle for so many months.

So anyway I am glad that we don't have that many missing puzzle pieces because even though it is a small thing I have the belief that it matters. 


The concept was reinforced when our OT student intern was able to open the door today - she has struggled with the 'child safety cover' on the door handle for her entire fieldwork experience.  This afternoon she opened up the door on the first try and at the same time we both cheered, "HOORAY!"  Again, it is a small thing that matters.



I have also been thinking about…

Occupational therapy private practice: A day in the life

I received an email yesterday from an anonymous commenter who wanted to know what one of my actual days looked like as a private practitioner.  So here goes a listing of what happened today, which seems as representative as any other day :D :

4:30am Wake up.  Read email, respond to email.  Check local and national headlines, reading 1-2 articles of interest.  Check Internet forums, respond to messages.  Look at clock and sigh.

5:15am Go back to sleep. 

7:15am Wake up, again.  While having breakfast read email, respond to email.  Complete a journal and focused medical news scan, reading 1-2 articles of interest. Check Internet forums, respond to messages.  Look at clock and sigh.

8:30am  Wonder why children are still sleeping, pay attention to the cat and dog, leave for the office.

8:50am Arrive at office.  Meet with parents in the waiting room while their children are in for therapy.  Banter, advise, support.  Repeat as needed.  Schedule meetings to resolve lingering issues with ma…

Special interests drive language changes to OT Assistant laws in NY State

As I blogged about earlier this year, there were some problems with the changes to the NY State occupational therapy law that placed significant barriers to non traditional fieldwork settings.  OTA fieldwork educators in New York State and NYSOTA saw these problems and there was a last minute rush to file a technical amendment to the law so that they would not have to operate under such restrictive conditions.

It is true that the way the law was written could have contributed to a decreased pool of practitioners able to accept fieldwork students; OTA students would have had to compete with OT students for licensed occupational therapy supervisors.  Fieldwork educators already struggle to find 'slots' for their students and the law certainly did not help by imposing restrictive limits on WHO could supervise a student.

However, restrictions are in place for a reason - namely to protect the public - and both Medicare and Medicaid have rather severe restrictions that functionally …