Skip to Main Content

Print | Bookmark | Email | Font Size: + | –

August 21, 2018

Documenting the Medical Necessity of Therapy Services

Medical review denials for physical therapy (PT) and occupational therapy (OT) services are often made due to lack of documentation of medical necessity.  All services billed to Medicare must meet the criteria of "medically necessary and reasonable." To determine whether a service is reasonable and necessary, the Medicare home health benefit considers each beneficiary's unique medical condition. The medical record documentation provides the basis for this determination. Coverage decisions are always based upon the objective clinical evidence of the beneficiary's individual need for care.

It is the home health agency's responsibility to provide clear documentation of the medical necessity and reasonableness. This includes: progress or lack of progress, medical condition, functional losses, and measurable short and long treatment goals.

Physical Therapy
Physical therapy can be vital in rehabilitating a beneficiary after a change in condition, and increasing the beneficiary's abilities back to a functional status in the home. The services are provided with the expectation, based on the assessment made by the physician of the beneficiary's rehabilitation potential, that the condition will improve materially*in a reasonable and predictable period of time, or the service is necessary to establish a safe and effective maintenance program. A Local Coverage Determination for physical therapy servicesExternal Websiteis available to assist providers in determining appropriateness of physical therapy services, based on the beneficiary's functional condition

Follow these two main guidelines to demonstrate that therapy services are reasonable and medically necessary.

  1. Document the complexity of the treatment
    • Any tests, measures, assessment
    • Planning, interventions, changes
    • Teaching and assessment of patient's ability to follow through
    • Continued need for assessment and teaching – show the assistance provided, the assessment, the plan for changes, and other interventions
      • Example: When assessing gait, rather than just "ambulated ten feet," it would be more complete to state: "Patient continues to push FWW several feet in front, without a step-through gait. Patient began to lose balance, caught by this physical therapist. Voice commands provided to step through and into walker, and patient able to ambulate 10ft with this assist."
    • Avoid documenting repetitive modalities and interventions
  2. Document why treatment is medically appropriate, based on beneficiary's condition
    • Patient's needs, functional changes or changes in condition
    • Prior level of function
    • Document any other conditions that may support need for therapy in situations that wouldn't ordinarily need a therapist
    • Example: A patient needs ongoing range of motion on left leg. Often a home health aide or family member could provide this after being taught. This patient needs the therapist to do the range of motion because they have a non-healing fracture.

Occupational Therapy
Visits by an occupational therapist to assess and reassess a beneficiary's rehabilitation needs and potential, or to develop and/or implement an occupational therapy program, are covered when reasonable and necessary because of the beneficiary's condition. It should be clear in the documentation that the occupational therapist is working on functional limitations and tasks with the beneficiary.

Follow these two main guidelines to demonstrate that occupational therapy services are reasonable and medically necessary.

  1. Document the complexity of the treatment
    • Any tests, measures, assessment
    • Planning, interventions, changes
    • Teaching and assessment of patient's ability to follow through
    • Continued need for assessment and teaching – show the assistance provided, the assessment, the plan for changes, and other interventions
    • Avoid documenting repetitive modalities and interventions
  2. Document why treatment is medically appropriate, based on beneficiary's condition
    • Patient's needs, functional changes or changes in condition
    • Prior level of function
    • Document any other conditions that may support need for therapy in situations that wouldn't ordinarily need a therapist

Resources:

*--The term "materially" means having real importance to consequences, to an important degree, or the improvement can be perceived in material form (objectively). In general, there should be a reasonable expectation that observable improvement in the overall safety of functional ability will occur.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved