Documenting Medical Necessity of Physical Therapy
Follow these two main guidelines to demonstrate that 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
- Example: When assessing gait, rather than just "ambulated ten feet," "Patient continues to push FWW several feet in front, without a step-through gait. Patient began to lose balance, caught by this physical therapist. Voice commands provided to step through and into walker, and pt able to ambulate 10ft with this assist."
- 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
- Example: A patient needs ongoing range of motion on left leg. Often a home health aide or family member could provide this after being taught. This patient needs the therapist to do the range of motion because they have a non-healing fracture.
Updated: 01.12.17