Documenting Medical Necessity of Occupational Therapy
Follow these two main guidelines to demonstrate that occupational therapy services are reasonable and medically necessary.
- Document the complexity of the treatment
- Any tests/measures/assessment
- Planning, interventions, changes
- Teaching and assessment of patient's ability to follow through
- Continued need for assessment and teaching – show the assistance provided, the assessment, the plan for changes, and other interventions
- Avoid documenting repetitive modalities and interventions
- Document why treatment is medically appropriate, based on beneficiary's
condition
- Patient's needs, functional changes or changes in condition
- Prior level of function
- Document any other conditions that may support need for therapy in situations that wouldn't ordinarily need a therapist
Posted: 09.27.11