Billing and Coding: Medical Necessity of Therapy Services

Medical records must support medical necessity of therapy services provided
e.g., Are the services appropriate for the patient's condition and do the
services require the skills and knowledge of a qualified clinician? For
detailed guidance, view the CMS Internet Only Manual (IOM), Publication
100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220-230. The
requirements in these sections describe a standard of care that is anticipated
throughout the therapy plan of care for each discipline. To meet Medicare's
standard of coverage all of the following requirements must be met.  
  
 **Qualified Clinician**  
Therapy services must be provided by a qualified clinician i.e., physician,
non-physician practitioner (NPP), therapist, or speech-language pathologist
(SLP). Treatment services may also be provided by an appropriately supervised
physical therapy (PT) or occupational therapy (OT) assistant. Services
provided by a therapy aide with or without qualified clinician supervision are
not reimbursable in any therapy setting. For additional information, see the
attached _Billing and Coding:_ _Therapy Students and Aides_ article in the
Related Local Coverage Documents link below.  
  
 **Skilled Level of Care**  
Skill is a level of expertise acquired through specialized training not
attained by the general population. While a patient's medical condition is a
valid factor in deciding if skilled therapy services are needed, a patient's
diagnosis or prognosis is never the sole factor in deciding that a service is
or is not skilled. The key issue is whether the skills of a therapist are
needed to treat the illness or injury, or whether the services can be carried
out by non-skilled personnel after sufficient training.  
  
To demonstrate that services are at a skilled level of care, the medical
record must support that the expertise and knowledge of a qualified clinician
was necessary and was provided. Documentation needs to clearly indicate the
clinician's unique professional contribution to the therapy services e.g., Why
did the patient require professional treatment, education or training? What
specialized treatment, education or training did the clinician actually
provide? How did the patient benefit from the specialized knowledge applied by
the clinician?  
  
Skilled land and water-based therapy programs require that the patient have
direct one-on-one contact with the qualified clinician throughout the
procedure. The services of a qualified clinician cannot be billed for
supervising a patient that is independently completing an exercise program.
Additionally, ongoing repetitive exercises that do not demonstrate the need
for continued hands-on involvement and/or teaching by the qualified clinician
would not be considered to be at a skilled level of care. Documentation must
support that the therapy sessions are at a level of complexity that requires
ongoing qualified clinician input.  
  
**Medical Necessity - Rehabilitation**  
Services must be under accepted standards of medical practice and considered
to be specific and effective treatment for the patient's condition. The
amount, frequency, and duration of the services planned and provided must be
reasonable. Services must be necessary for treatment of the patient's
condition: The medical record must clearly describe the patient's condition
before, during, and after the therapy episode to support that the patient
significantly benefited from ongoing therapy services and that the progress
was sustainable and of practical value when measured against the patient's
condition at the start of treatment. Documentation of comparable
objective/functional measures plays a key role in demonstrating medical
necessity.

**Example of acceptable and unacceptable comparative measures:**

  * _Acceptable_ comparative measure: At the time of the initial evaluation it was documented that the patient had an objective manual muscle test (MMT) of 3/5 for right knee extension. Documentation in the 10 day progress report supported that the patient had achieved 4/5 for right knee extension which demonstrated significant benefit for the patient.
  * _Unacceptable_ comparative measure: At the time of the 10 day progress report the documentation supported that the patient had an objective MMT of 4/5 for right biceps flexion. At the time of the 20 day progress report documentation supported that the patient was able to complete 3 sets of 10 repetitions for right biceps flexion during each therapy visit. Since the MMT information is not directly comparable to the therapeutic exercise sets and repetitions this comparison does not clearly demonstrate ongoing significant benefit for the patient and may result in denial.

These objective/functional measures must minimally be established for the
patient's prior level of function (PLOF), status at the initial evaluation,
and status at each progress reporting interval. Qualified clinicians must
complete the progress reports a minimum of every ten treatment days throughout
the episode of care. The progress reporting interval does not match the
interval for physician certification of therapy services which may extend up
to 90 calendar days.  
  
Successful rehabilitation therapy requires the attainment of significant
progress for a reasonable period of time beyond the immediate intervention.
Services should not be repetitive, palliative, or simply reinforcing
previously learned skills or maintaining function. In most instances, the goal
of therapy is to maximize patient/caregiver abilities within the patient's
home environment. It is expected that the patient's treatment goals and
achievements during the therapy episode will reflect significant and timely
progress toward this end. As a result, during the therapy episode, the
emphasis of therapy will generally shift from traditional, patient-centered
therapeutic services to patient/caregiver education in order to prepare the
patient for a safe transition to an effective maintenance program. The
expectation is that the patient/caregiver will be compliant in performing the
established maintenance program to help prevent relapse. If therapeutic gains
from prior therapy services are tenuous, such that additional concentrated
therapy is needed for non-skilled maintenance of the patient in their usual
living environment (that includes caregivers), then the goals of additional
therapy would be considered to be unrealistic.  
  
 **Medical Necessity - Maintenance**  
Medicare reimburses for the development of a medically necessary
individualized maintenance program to:

  * Maximize and retain the patient's functional status achieved with therapy services;
  * Assure patient safety within their home environment;
  * Train the patient and/or caregiver in the maintenance activities;
  * Prevent further decline in the patient's condition.

Medicare does not reimburse for carrying out maintenance activities when:

  * The activities do not require the skills of a qualified clinician i.e., the level of complexity and sophistication of the activities do not require the performance and/or supervision of a therapist.
  * The condition of the patient is such that the services do not require the performance and/or supervision of a therapist.
  * The activities can reasonably be provided by non-skilled personnel after training is completed by the qualified clinician.

It is anticipated that once the maintenance program is established, updates to
the program will be necessary on an infrequent basis.

When additional medical necessary services are required for the same medical
condition, a thorough initial evaluation should be completed for the patient
who was previously discharged. Documentation for maintenance program revisions
must support that any additional therapy services require the performance
and/or supervision of a qualified therapist due to the
complexity/sophistication of the required procedures and/or the condition of
the patient. The documentation must clearly indicate why a revision of the
maintenance program is necessary and what specific revision(s) are needed. Key
documentation components include:

  * Was the patient/caregiver compliant with their previously established maintenance program?
  * Was the patient unable to complete the maintenance program? Why?

Are there any _new_ significant medical and/or functional issues noted since
discharge from prior therapy that necessitate revision of the maintenance
program?  
  
For additional information, see the attached _Billing and Coding: Therapy
Evaluation, Re-Evaluation and Formal Testing_ article in the Related Local
Coverage Documents link below.  
  
 **_Sources_**

  * **_Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3, Section O_**
  * **_CMS Inpatient Rehabilitation Facility (IRF) Training Q &A Series 4 Section V, #33_**
  * **IOM,[Medicare Benefit Policy Manual](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c01.pdf), Publication 100-02, Chapter 1, Section 110**
  * **IOM,[Medicare Benefit Policy Manual](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf), Publication 100-02, Chapter 15, Sections 220-230.**