Home Health & Hospice

Q: I find that my newer staff struggle to understand what medical necessity really means? Can you help provide some clarity?

Homecare Insider, November 11, 2013

Q: I find that my newer staff struggle to understand what medical necessity really means? Can you help provide some clarity?

A: The term “medical necessity” is used often in healthcare but can lack clarity to the individual clinician. It is helpful to consider the dictionary definition of the word “necessity”—which contains a very helpful piece of the puzzle—indispensability. The fact that a person has a medical condition such as congestive heart failure does not automatically mean that nursing or therapy services are warranted.

There are plenty of people of Medicare age with a diagnosis of heart failure, diabetes, or peripheral vascular disease who are not in need of skilled care. That being said, accurate diagnosis coding is a critical element of the home health admission assessment as it communicates to Medicare and other payers the complexity of the patients being served.

The support for necessity is driven by what the individual discipline can provide to a patient that could not be provided as well or at all by another discipline, a family member, or caregiver. The medical condition can set the stage, but the key element is defining what the specific discipline (e.g., physical therapy, occupational therapy, or speech-language pathology) is going to provide to the patient that will have a meaningful impact. Progress in the traditional sense may occur because of these interventions but will not stand alone to show skill.