Please note that this article contains information that is only relevant to American clinics.
In outpatient PT, OT, and SLP therapy services, there are two distinct kinds of therapy: habilitative therapy and rehabilitative therapy. In recent months, many insurance carries, along with certain state Medicare programs, have changed their coverage guidelines based on whether the therapy is considered to rehabilitative or habilitative by nature. In this article, we’ll spend some time defining habilitative and rehabilitative therapy, provide you with some examples of them, and explain the differences between the two.
What is rehabilitative therapy?
Rehabilitative therapy is a type of treatment or service that seeks to help a patient regain a skill or function that was lost as a result of injury or sickness. Allow me to provide you with an imaginary scenario where a patient would require rehabilitative therapy.
Let’s pretend that there is 39-year-old woman who was in an auto accident. As a result, she fractured her ankle and is unable to walk without a limp. Unhappy with her new gait, this woman has opted to seek the help of a physical therapy professional to overcome her issue.
This type of treatment is considered to be rehabilitative because the patient did not walk with a limp prior to the accident. Their injury can be directly attributed to the accident, and they are seeking to restore themselves to their former functionality.
What is habilitative therapy?
Habilitative therapy is a type of treatment or service that seeks to help patients develop skills or functions that they were incapable of developing on their own. This type of treatment tends to be common for pediatric patients who haven’t developed certain skills at an age-appropriate level. Let’s take a look at a scenario where this might be the case.
Let’s imagine that a 5-year-old boy’s mother received an email from the teacher about their child’s behaviour in the classroom. Apparently he is unable to remain seated through lessons, he appears to have boundless energy, and is generally disruptive. As such, the mother has chosen to take their child to see a behavioural psychologist where he is subsequently diagnosed with ADHD, and a treatment plan is created.
The treatment received by the 5-year-old boy can be considered habilitative because the child has been unable to develop the necessary skills to remain focused in the classroom, despite many of his peers being perfectly capable.
Type of Therapy and Claims Submissions
A recent article from Gawenda Seminars and Consulting stated that “Prior to January 1, 2017, most insurance carriers did not require providers to distinguish between rehabilitative and rehabilitative therapy on the claim form.” But many payors now require therapists to specify this on dates of service after January 1, 2017. There’s actually a modifier that therapists need to use to indicate habilitative therapy—SZ. So, if you’re in doubt about whether you need to explicitly state which type of treatment you’re providing, do yourself a favor and contact their insurance carrier for more information.