Home Health & Hospice

Insider’s Scoop | The basics of determining medical necessity for therapy

Homecare Insider, January 4, 2016

Editor’s note: This week’s Insider’s Scoop is from Documenting Medical Necessity: A Practical Guide for Home Health. In this book, author Heather Calhoun, RN, BSN, HCS-D, COS-C, provides down-to-earth, conversational documentation tips with dozens of example scenarios to help nurses understand the tricky parts of medical necessity and document in a manner that encourages proper and complete reimbursement. For more information or to order, call customer service at 800-650-6787 or click here.

In order for speech, physical, and occupational therapy to be reasonable and necessary, the therapist must document the connection between the patient’s functional loss/illness and the need for the unique skills of the therapist to manage and oversee the patient’s therapy program in the home. These services must bring the patient back to his or her prior level of service or maintain current function with slowing or prevention of decline. If there is a reasonable expectation that the patient will recover from an episode of illness without the need of the therapist, then the care would not be reasonable and necessary.

The question that the therapist has to ask before deciding whether therapy services are medically necessary is: "Would the patient have improved or stabilize without the interventions of the therapist?" 

If the therapist can document and prove on paper that, without the help of therapy, the patient would be at risk for more issues/injuries/rehospitalizations, then he or she has just proven medical necessity. This takes looking at the whole patient, not just his or her functional limitations. The therapist has to tell on paper how the patient maneuvers about the home, what devices he or she currently has or needs, ability to exit the home and maneuver outside if appropriate, and what and how he or she is currently doing that could potentially jeopardize his or her health, safety, and recovery. These are the items that must be documented at the time of evaluation, reevaluation, and on each routine note.