Knowledge Base Article

For this newsletter, I often write articles about other articles. I expect the quality and worth of the articles I write are judged by our readers, and likewise, I have an opinion on the worth of the articles I reference. Therefore, I have to applaud Palmetto GBA on their article on Therapeutic Exercise. This is one of the most comprehensive yet concise explanations of the requirements for therapy services I have seen. I will note some of the major points in my discussion below, but I encourage anyone who has a vested interest in this topic to read Palmetto’s article. In fact, I recommend you print and/or save it electronically for future reference. I know I will.

One of the main reasons for Medicare denials of therapy services is the lack of medical necessity. The Palmetto article breaks this down to 4 points and then discusses each of the requirements in more detail. 

“Medical necessity — four main requirements

• Presence of a disabling condition
• Individualized treatment
• Expectation that the beneficiary will benefit from therapy
• Requires skilled care”

Presence of a disabling condition

It seems obvious that the patient must have an injury, post-surgical limitations, or a medical condition that requires therapy. The issue is that there must be documentation beyond simply stating the medical problem. Documenting the patient has a sprained ankle, is post-surgical from a rotator cuff repair, or had a stroke is not enough. The therapist performing the evaluation needs to include the functional deficits the patient has and how these affect the patient’s ability to perform activities of daily living (ADLs). For example, following a shoulder injury or surgery, the patient could have pain, swelling, weakness, and limited range of motion that results in an inability to perform dressing and self-care independently. I like to think of documenting times 3 –

1. the medical condition, such as post-surgical repair of torn rotator cuff,
2. the symptoms and deficits, such as pain, swelling, weakness, and limited range of motion (be sure to include objective measures), and
3. the activity limitations and participation restrictions in the patient’s daily life, such as patient is unable to reach up to wash hair, dress independently and perform house-keeping chores.

The Palmetto articles states, “Per the LCD, include one of the following: weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance (pain is not listed, but it is acceptable as pain typically can cause several of the above conditions).”

Individualized treatment

This is the Plan of Care (POC) where the therapist selects the types of exercises, amount, frequency, and duration of treatment tailored to the specific patient’s needs and abilities. In listing the goals, the therapist can tie the types of exercises chosen to the patient’s activity limitations or participation restrictions identified. For example, therapeutic exercises may be performed to increase strength and improve range of motion to allow the patient to be able to perform self-care activities independently.

Again, from the Palmetto article – “Per the LCDs, goals should address the following: patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation.”

Expectation that the beneficiary will benefit from therapy

If you do not think it would benefit the patient, you should not be doing it. The goals included in the POC should address your expectations of the benefits the patient will have from the therapy. The progress reports as the patient participates in therapy will hopefully reflect the benefits the therapist expected from the therapy treatment. These should include objective measures, such as measures of the patient’s range of motion or strength, and subjective observations and patient reports of improvements in their abilities to perform ADLs. Not all patients respond as expected – if a patient is not benefiting from therapy, the therapist may modify the plan or discontinue therapy.

Notice that this says the beneficiary should “benefit” from therapy, not “improve” from therapy. That is an important distinction since all patients may not be able to improve, but therapy is needed to prevent or slow further decline in functional status. This is acceptable for Medicare coverage, but the expectation and outcomes should be clearly documented.

Requires skilled care

The treatments provided to the patient must require the skills of a therapist or therapy assistant under the direction of a therapist. If the services could be provided by someone without the skills of a therapist, then the services do not meet Medicare’s requirements for skilled care. Skills may include providing instructions on proper exercise form, direction to the patient during exercises, providing assistance, ensuring the safety of the patient during the performance of treatment, and/or monitoring the patient medically. The requirement for skilled care is addressed in the evaluation, plan of care, and in the daily treatment notes, where the therapist might document cueing the patient, instruction in proper form, or stand-by assist for patient safety, for example. The Palmetto article points out “Keywords in documentation to support use of skilled care (are) educate, education, corrected, instruct, instruction, trained, directed, reassessed, medical monitoring.”

As long as patients are benefiting from therapy and continue to require skilled care, documentation in the record must indicate the patient’s progression and the continuing need for the skills of the therapist. Once a patient is able to perform exercises independently or with non-skilled assistance, therapy services are no longer covered by Medicare. Patients may continue with a home or gym exercise program on their own.

The Palmetto article goes on to discuss all the different types of required therapy documents and what needs to be included in each – evaluation, plan of care, certification/recertification, progress reports, and treatment notes. Medical necessity is whether the patient needs therapy, but therapy documentation provides the support for that medical necessity in addition to supporting the services provided. That is a big job for words on a page. And Medicare will be judging the quality and worth of that writing.