evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
D.  Delayed Certification   References:  1835(a)  of the Act  42CFR424.11(d)(3)   Certifications are required for each interval of treatment based on the patients needs, not to exceed 90 calendar days from the initial therapy treatment.  Certifications are timely when the initial certification (or certification of a significantly modif ied plan of care) is dated within 30 calendar days of the initial treatment under that plan.  Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whicheve r is less.  Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.  Certifications are acceptable without justification for 30 days after they are due.  Delayed certification should include one or more certifications or recertifications on a single signed and dated document.  Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay.  For example, a certification may be delayed because the physician did not sign it, or the original was lost.  In the case of a long delayed certification (over 6 months), the provider or supplier may choose to submit with the delayed certification some other documentation (e.g., an order, progress notes, telephone contact, requests for certification or signed statement of a physician/NPP) indicating need for care and that the patient was under the care of a physician at the time of the treatment. Such documentation may be requested by the contractor for delayed certifications if it is required for review.   It is not intended that needed therapy be stopped or denied when certification is delayed.  The delayed certification of otherwise covered services should be accepted unless the contractor has reason to believe that there was no physician involved in the patients care, or treatment did not meet the patients need (and therefore, the certification was signed inappropriately).
(Medicare Benefit Policy Manual)
EXAMPLE:   Payment should be denied if there is a certification signed 2 years after treatment by a physician/NPP who has/had no knowledge of the patient when the medical record also shows e.g., no order, note, physician/NPP attended meeting, correspondence with a physician/NPP, documentation of discussion of the plan with a physician/NPP, documentation of sending the plan to any physician/NPP, or other indication that there was a physician/NPP involved in the case.   EXAMPLE:  Payment should not be denied, even when certified 2 years after treatment, when there is evidence that a physician approved needed treatment, such as an order, documentation of therapist/physician/NPP discussion of the plan, chart notes, meeting notes, re quests for certification, certifications for intervals before or after the service in question, or physician/NPP services during which the medical record or the patients history would, in good practice, be reviewed and would indicate therapy trea tment is in progress.   EXAMPLE:   Subsequent certifications of plans for continued treatment for the same condition in the same patient may indicate physician certification of treatment that occurred between certification dates, even if the signature for one of the plans in the episode i s delayed.  If a certified plan of care ends March 30th and a new plan of care for continued treatment after March 30th is developed or signed by a therapist on April 15th and that plan is subsequently certified, that certification may be considered delaye d and acceptable effective from the first treatment date after March 30th for the frequency and duration as described in the plan.  Of course, documentation should continue to indicate that therapy during the delay is medically necessary, as it would for any treatment.  The certification of the physician/NPP is interpreted as involvement and approval of the ongoing episode of treatment, including the treatment that preceded the date of the certification unless the physician/NPP indicates otherwise.   E.  Denials Due to Certification   Denial for payment that is based on absence of certification is a technical denial, which means a statutory requirement has not been met.  Certification is a statutory requirement in SSA 1835(a)(2) - (periodic review of the plan).
(Medicare Benefit Policy Manual)
For example, if a patient is treated and the provider/supplier cannot produce (on contractor request) a plan of care (timely or delayed) for the billed treatment dates certified by a physician/NPP, then that service might be denied for lack of the required certification.  If an appropriate certification is later produced, the denial shall be overturned.   In the case of a service furnished under a provider agreement as described in 42CFR489.21, the provider is precluded from charging the beneficiary for services denied as a result of missing certification.   However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability.  For that reason, it is recommended that the patient be made aware o f the need for certification and the consequences of its absence.   A technical denial decision may be reopened by the contractor or reversed on appeal as appropriate, if delayed certification is later produced.  220.1.4 - Requirement That Services Be Furnished on an Outpatient Basis  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Reference:  42CFR410.60  Therapy services are payable under the Physician Fee Schedule when furnished by 1.) a provider to its outpatients in the patients home; 2.) a provider to patients who come to the facilitys outpatient department;  3.) a provider to inpatients of other ins titutions, or 4.) a supplier to patients in the office or in the patients home.  (CORF rules differ on providing therapy at home.)   Coverage includes therapy services furnished by participating hospitals and SNFs to their inpatients who have exhausted Part A inpatient benefits or who are otherwise not eligible for Part A benefits.  Providers of therapy services that have inpatient faci lities, other than participating hospitals and SNFs, may not furnish covered therapy services to their own inpatients.  However, since the inpatients of one institution may be considered the outpatients of another institution, all providers of therapy services may furnish such services to inpatients of another health facility.
(Medicare Benefit Policy Manual)
A certified distinct part of an institution is considered to be a separate institution from a nonparticipating part of the institution.  Consequently, the certified distinct part may render covered therapy services to the inpatients of the noncertified par t of the institution or to outpatients.  The certified part must bill the A/B MAC (A) under Part B.  Therapy services are payable when furnished in the home at the same physician fee schedule payment rates as in other outpatient settings.  Additional expenses incurred by providers of outpatient therapy due to travel to the beneficiary are not covered.  Under the Medicare law, there is no authority to require a provider to furnish a type of service.  Therefore, a hospital or SNF may furnish therapy to its inpatients without having to set up facilities and procedures for furnishing those services to its outpatients.  However, if the provider chooses to furnish a particular service, it may not charge any individual or other person for items or services for which the individual is entitled to have payment made under the program because it is bound by its agreement with Medicare.  Thus, whenever a hospital or SNF furnishes outpatient therapy to a Medicare beneficiary (either directly or under arrangements with others) it must bill the program under Part B and may charge the patient only for the applicable deductible and coinsurance.  220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services  (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)    References:  Pub. 100-08, chapter 13, 13.5.1, 42CFR410.59 , 42CFR410.60   A.  General
(Medicare Benefit Policy Manual)
References:  Pub. 100-08, chapter 13, 13.5.1, 42CFR410.59 , 42CFR410.60   A.  General   To be covered, services must be skilled therapy services as described in this chapter and be rendered under the conditions specified.  Services provided by professionals or personnel who do not meet the qualification standards, and services by qualified people that are not appropriate to the setting or conditions are unskilled services.  A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist.  If a service can be self -administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service.  Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service whe n a therapist furnishes the service.   Skilled therapy services may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.  For further information see 220.2, subsections C (Reha bilitative Services) and subsection D (Maintenance Programs).   Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services.  For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes.  Also, services not provided under a therapy plan of care, or provided by staff who are not qualified or appropriately supervised, are not payable therapy services.  Examples of coverage policies that apply to all outpatient therapy claims are in this chapter, in Pub. 100-04, chapter 5, and Pub. 100-08, chapter 13 .  Some policies in other manuals are repeated here for emphasis and clarification.  Further details on documenting reasonable and necessary services are found in section 220.3 of this chapter.  B.  Reasonable and Necessary
(Medicare Benefit Policy Manual)
B.  Reasonable and Necessary   To be considered reasonable and necessary, each of the following conditions must be met. (This is a representative list of required conditions and does not fully describe reasonable and necessary services.  See the remainder of this section and associated information in section 230.)   The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patients condition.  Acceptable practices for therapy services are found in:   o Medicare manuals (such as this manual and Publications 100-03 and 100- 04),  o Contractors Local Coverage Determinations (LCDs and NCDs are available on the Medicare Coverage Database:  http://www.cms.hhs.gov/mcd , and  o Guidelines and literature of the professions of physical therapy, occupational therapy and speech -language pathology.   The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.  Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.  Medicare coverage does not turn on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  (For additional guidance, see subsection D below related to Maintenance Programs.)    If the contractor determines the services furnished were of a type that could have been safely and effectively performed only by or under the supervision of such a qualified professional, the contractor shall presume that such services were properly superv ised when required.  However, this presumption is rebuttable and, if in the course of processing a claim, the contractor finds that services were not furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office.
(Medicare Benefit Policy Manual)
 While a beneficiarys particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiarys diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.  The key issue is whe ther the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. See items C and D for descriptions of covered skilled services; and   The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.  The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines.
(Medicare Benefit Policy Manual)
 The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.  The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines.  NOTE :  Claims for therapy services denied because they are not considered reasonable and necessary under 1862(a)(1)(A) of the Act and, for services furnished on or after January 1, 2013, those denied as a result of application of the therapy caps under 1833(g)(1) or (g)(3) are subject to consideration under the waiver of liability provision in 1879  of the Act.  Although Section 50202 of the Bipartisan Budget Act (BBA) of 2018 repealed the therapy caps and its exceptions process effective January 1, 2018, it did not change provider liability procedures which first became effective January 1, 2013. Section 1833(g)(8) of the Social Security Act (as redesignated by the BBA of 2018) continues to provide limitation of liability (LOL) protections to beneficiaries receiving outpatient therapy services on or after January 1, 2013, when services are denied for certain reasons, including failure to include a necessary KX modifier. (Section 1879 provides LOL protections for reasonable and necessary denials more generally.) Under section 1833(g)(8), the therapist or therapy provider is financially liable for the cost of therapy services provided to a beneficiary above the threshold amount when Medicare denies payment for failure to use the KX modifier to indicate that the services are medically necessary as justified by documentation in the medical record. In or der for the therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid ABN, Form CMS -R-131.  For more information, see the Therapy Services webpage at:  https://www.cms.gov/Medicare/Billing/TherapyServices/index.html  for the Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document that was posted to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document titled: August 2018 ABN FAQs in the Downloads section on this webpage.
(Medicare Benefit Policy Manual)
C.  Rehabilitative Therapy  Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.  Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, decrease in severity or rationalization for an optimistic outlook to justify continued treatment.  Improvement is evidenced by successive objective measurements whenever possible (see objective measurement and other instruments for evaluation in the 220.3.C of this chapter).  If an individuals expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.   Rehabilitative therapy services are skilled procedures that may include but are not limited to:   Evaluations and reevaluations;    Establishment of treatment goals specific to the patients disability or dysfunction and designed to specifically address each problem identified in the evaluation;    Design of a plan of care addressing the patients disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment;   Continued assessment and analysis during implementation of the services at regular intervals;    Instruction leading to establishment of compensatory skills;    Selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short -term training on use of the device or system); and    Training of patient and family to augment rehabilitative treatment.  Training of staff and family should be ongoing throughout treatment and instructions modified intermittently as the patients status changes.   Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.  (See definition of therapist in section 220.A of this chapter.)  Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services.
(Medicare Benefit Policy Manual)
Rehabilitative therapy may be needed, and improvement in a patients condition may occur, even when a chronic, progressive, degenerative, or terminal condition exists.  For example, a terminally ill patient may begin to exhibit self -care, mobility, and/or safety dependence requiring skilled therapy services.  The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patients condition or to maximize his/her functional abilities.  The deciding factors are always whether the services are considered reasonable, effective treatments for the patients condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel.  Rehabilitative therapy is not required to effect improvement or restoration of function when a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary and generalized weakness, which may follow a brief period of bed rest following surgery) that could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.  Therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individuals illness or injury and the services are not covered.  If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, the services will no longer be considered reasonable and necessary under this section.  (See Section 220.2 D for additional covered therapy benefits under maintenance programs).  Services that are not reasonable or necessary are excluded from coverage under 1862(a)(1)(A) of the Act.   D.  Maintenance Programs
(Medicare Benefit Policy Manual)
D.  Maintenance Programs   Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program.  The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.  Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:   Establishment or design of maintenance programs.   If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patients current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered.  If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, su ch instruction is covered.  If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.    Delivery of maintenance programs.   Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiarys need for skilled care.  A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel.  In such situations, coverage is not provided.  However, skilled therapy services are covered when an individualized assessment of the patients clinical condition demo nstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.  Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patients current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patients special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patients current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy proced ures.  Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patients potential for improvement from the therapy.