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Documenting Medical Necessity of Occupational Therapy

Follow these two main guidelines to demonstrate that occupational therapy services are reasonable and medically necessary.

  1. 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
  2. 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

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