Criteria for Coverage

• What conditions are required to furnish outpatient therapy for Medicare patients?
• How do I demonstrate that the patient needs therapy services?
• How do I show that the plan is periodically reviewed by a physician/NPP?
• How can I document that the patient is or was under the care of a physician?

Orders/Referrals

• Does Medicare require an order or referral?
• Does Medicare require that the patient visit the physician?
• Which providers can certify a POC?
• Which providers cannot certify a POC?

Evaluations/Reevaluations

• Who can perform a therapy evaluation?
• When does an evaluation need to be performed?
• Can an evaluation and treatment be performed on the same visit?
• What must be included in the evaluation?

Progress Reports

• Who must complete the progress report?
• Who must sign the report?
• When does the progress report need to be completed?
• What happens if the report is delayed?

Discharge Summary

• Is a discharge summary required for every patient?
• What if the patient just stops coming to therapy?
• What is required on the discharge summary?

Assistants

• What level of supervision is required for PTAs and OTAs?
• Are services provided by SLPA covered?
• Can PTAs and OTAs perform services incident to a physician/NPP?
• What role can PTAs and OTAs take part in the progress report?

Appeals

Medical Necessity

• When are services considered to be medical necessary under Medicare rules?
• When are services considered to not be medically necessary?
• What should be included in a POC for rehabilitative therapy?
• What conditions are required in order for a maintenance program to be covered?

Certification/Recertification 

• What does Medicare require for a certification?
• When does the POC need to be certified?
• Can the certification be done verbally?
• When is recertification required?

Plan on Care

• Who can establish a therapy plan of care (POC)?
• Who must sign the POC?
• Can treatment begin before a POC has been established?
• What must be included in the POC?

Treatment Notes

• When are treatment notes required?
• What is required to be included in the treatment note?
• Who must sign the treatment note?
• Does the supervisor’s signature need to be on the note?

Modifiers

• Which modifiers have to appended to all therapy claims?
• When does the KX modifier need to be added to the claim?
• When do the CO/CQ modifiers need to be added to claims?

Other Assistive Personnel

ABNs