When are services considered to be medical necessary under Medicare rules?

Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

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.

When are services considered to not be medically necessary?

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.

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility).

Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.

Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion (for example: in paralyzed extremities).

Maintenance therapies after the patient has achieved therapeutic goals or for patients who do not require skilled care and should become patient or caregiver-directed.

What should be included in a POC for rehabilitative therapy?

Rehabilitative therapy services POC include but are not limited to:

• Establishment of treatment goals specific to the patient’s disability or dysfunction and designed to specifically address each problem identified in the evaluation;
• Design of a plan of care addressing the patient’s 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 patient’s status changes.

What conditions are required in order for a maintenance program to be covered?

Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates 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:

• The therapy procedures required to maintain the patient’s 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
• The particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures.

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 patient’s potential for improvement from the therapy.

References

Medicare Benefit Policy Manual Ch. 15 §220.2

Billing and Coding: Medical Necessity of Therapy Services: A52775