• Therapy is not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist. Except in cases of maintenance therapy, therapy is not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate.
• Therapy is not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected. The skills of the therapist are not required to maintain function.

• Enhancing already evident/existing functional status is not reasonable and necessary; therefore noncovered.

• Therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve over time without the services of the therapist. It is necessary to determine if individual therapy services are skilled, and whether, in view of the patient’s overall condition, skilled management of the services provided is needed although many or all of the specific services needed to treat the illness or injury do not require the skills of a therapist.  The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether non-skilled personnel can carry out the services. 

• Therapy services provided routinely to identify patients who might need or benefit from therapy intervention are not covered.

• Therapy services duplicative of other concurrent rehabilitation services are not covered.

• Therapy visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient's condition improves.

• Services that are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.

• The education component of treatment should begin at the start of care and continue until discharge. Continued visits to exclusively teach the HEP are not covered in the absence of documentation supporting ongoing education throughout the patient's entire course of treatment.

Reference

Outpatient Physical and Occupational Therapy Services

L34049