Medical Necessity Documentation for Physical and Occupational Therapy

We recently published an article on how to make your documentation defensible. Therapists must also understand what constitutes a medically necessary claim. CMS defines a medically necessary service or supply as:

“needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

As you can see, this definition leaves a lot open for interpretation! But, Medicare’s Local or National Coverage Determinations are a good place to start. Similarly, other payers have criteria that are typically included in their policy guidelines. In general, though, the items that really matter for your medical necessity documentation are:

1. Severity of signs and symptoms
2. Medical risk vs. gain
3. Need/availability of the therapeutic intervention necessary to evaluate/treat the presenting condition

1) Severity of Signs and Symptoms

The assessment of signs and symptoms starts with a conversation with, and evaluation of, the patient. It ends in an accurate ICD-10 diagnosis. Utilize the ICD system to provide payers the severity of a patient’s condition at a glance.

Let’s review an example. For the sake of the example, note that a diagnosis of M75.100 is for an unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic.  An M75.122 diagnosis is a complete rotator cuff tear or rupture of left shoulder, not specified as traumatic. The example is this: if you diagnose M75.100 when you could have diagnosed M75.122, you are providing much less information than you may have. You may not have not fully conveyed the severity of the injury.

2) Medical Risk vs. Gain

As you choose your diagnosis, you will also use standard tests and measures to determine medical risk versus gain. These tests will help you choose your plan, and the interventions necessary to treat the patient’s condition. These, along with the patient’s ability to follow through, will aid in the assessment of the current condition and determine the goal required for treatment. If any of these assessments result in an adverse probability of improvement, the risk may outweigh the gain.

3) Therapeutic Intervention Necessity

If treatment is appropriate, the notes must continually address how the plan is medically appropriate, and which interventions will assist in meeting the next planned goal. Be sure your medical necessity documentation includes:

• The continued need for assessment and teaching
• The patient’s needs, functional changes, and changes in condition
• The patient’s prior level of function
• Any other conditions that may support the need for your specific therapy services

These specific medical necessity documentation requirements, and the guidelines of defensible documentation, will help therapists meet/exceed medical necessity. Although each insurer has their own rules, providing enhanced documentation will assist you and your billing department in determining how to appeal and justify billed claims. That then will ensure your patient’s receive their needed treatment, and you will receive your deserved payment. To further your knowledge on Medical Necessity, check out “Defining Medically Necessary Physical Therapy Services” written by the APTA in 2011.