Unit 2 Medical Necessity Flashcards
The Social Security Act 1862 (A)(I) states: “No payment may be made under part A or part B for any expenses incurred for items or services which are not ___________ for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Specific rules to determine what Medicare considers what reasonable and necessary for therapy services can be found in the Chapter 15 of the Medicare Benefit Policy Manual Section 220.2.
reasonable and necessary
Define skilled care.
when the knowledge, abilities, and clinical judgement of a PT are necessary to safely and effectively furnish a recognized therapy service whose goal is of the following:
improvement of an impairment or functional limitation, maintenance of functional status, prevention or slowing further deterioration in function
Define therapy services provided that are considered to be rehabilitative i.e., rehabilitation therapy per Medicare.
PT services that are designed to address recovery or improvement in function and when possible restoration to previous level of health and well-being
Compare and contrast when rehabilitation therapy is and is not reasonable and necessary according to Medicare.
-Is reasonable & medically necessary -Is not reasonable & medically necessary
-Is reasonable & medically necessary -Is not reasonable & medically necessary: when a pt suffers a transient and easily reversible loss or reduction of function that could reasonably be expected to improve spontaneously as the pt gradually resumes normal activity
List the types of things a PT does, that is considered “Skilled Therapy.”
-continually assess and analyze the pt during implementation of services at regular intervals.
-instruct and cue and guide pts during interventions to improve their function
-select devices to replace or improve a pt’s function
-train pts and family members to improve their function
Describe maintenance therapy.
therapy procedures are required to maintain the pt’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure
When is a maintenance program considered “Skilled” and covered by Medicare?
when an individualized assessment of the pt’s clinical condition demonstrates that the specialized judgement, knowledge and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program
When is a Maintenance Program no longer covered by Medicare?
once you document pt/caregiver independence
What therapy services are not covered by Medicare.
-services related to activities for the general good and welfare of the pts
-activities to provide diversion or general motivation
-services not provided under a therapy plan of care
-services provided by staff who are not qualified or appropriately supervised
What do you need to include in your documentation to ensure that Medicare will cover the services you provided?
-services are considered reasonable, effective treatments for the pt’s condition
-require the skills of a therapist
-services can NOT be safely and effectively carried out by non-skilled personnel or caregivers
When looking at the big picture of providing documentation that supports medical necessity, what are the 3 things you must communicate in your documentation for that particular patient?
-document that services are consistent with nature and severity of illness, injury, and medical needs
-document that services are specific, safe, and effective according to accepted medical practice
-document that skilled therapy is needed to maintain or improve function or to prevent or slow its deterioration
Where do you document Medical Necessity and Skilled Care?
a. Evaluations/Re-Evaluations:
b. Daily/Treatment Notes:
a. Evaluations/Re-Evaluations: in the assessment portion of the eval
b. Daily/Treatment Notes: in the objective portion what you did and MN in the assessment portion
Write 2 examples of documenting medical necessity and skilled care for a PT evaluation:
-TUG score indicated the pt is at high risk for falls
-the pt requires moderate assistance to safely complete all bed mobility. pt demonstrates decreased strength and motor control to roll or weight shift to either side putting the pt at risk for complications of skin breakdown.
In documenting skilled care for Daily notes, what do you need to include:
-type and level of skilled assistance given to the pt, the PT’s clinical decision making and continued analysis of progress or lack of progress
-type and amount of manual, visual, or verbal cues, used to assist the individual in completing the exercise or activity completely and correctly
-document why the interventions were chosen +/or why they are still necessary
-interventions should correlate to the impairment, activity limitation, participation restriction, and the goals stated in the plan of care
Practice writing a skilled statement for an intervention for each code listed below:
a. Therapeutic Exercise:
b. Gait Training:
c. Neuromuscular Re-education:
d. Therapeutic Activity:
e. Attended E-stim:
a. Therapeutic Exercise: straight leg raises - 2 sets of 15 reps w/ 10lb cuff weights; verbal cues given to emphasize setting quads before lifting weight
b. Gait Training:
c. Neuromuscular Re-education: mini-tramp controlled landings to half-squat x 10 reps; verbal cues for alignment of hip knee and ankle
d. Therapeutic Activity: modified American kettlebell swings x 5 reps with manual cues to control the squat with glute contraction
e. Attended E-stim:
