Rehab

Tips and tools for rehab professionals

Rehab Regs, October 17, 2008

Medicare may deny a claim due to it not having enough or appropriate documentation to show that the services rendered were reasonable and necessary according to the program guidelines. Medicare has established general guidelines about how to demonstrate medical necessity for therapy services. The principles apply to all therapy settings reimbursed by Medicare, including but not limited to outpatient, SNF Part A, and home health services. To be considered medically reasonable and necessary:

  • Services must be of a level of complexity and sophistication that requires specific knowledge, skill, and judgment, and services can only be performed by a licensed physical therapist (PT) or PT assistant practicing under the PT’s supervision, an occupational therapist or assistant practicing under his or her supervision, or a speech-language pathologist
  • The patient is expected to improve materially in a reasonable and generally predictable amount of time
  • The services are necessary to safely and effectively establish a maintenance program
  • Interventions must be consistent with accepted standards of medical practice and be specific for the condition of the patient
  • The intensity, frequency, and duration of treatment is reasonable and appropriate for the individual patient

This tip is from HCPro’s Pocket Guide to Therapy Documentation.

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