The goal of rehabilitative medicine is recognizable, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function.
Medicare covers therapy services personally performed only by one of the following:
Licensed Physical Therapists
Occupational Therapists
Speech Language Pathologists
Licensed physical therapy assistants when supervised directly by a licensed Physical Therapist
Licensed occupational therapy assistants when supervised directly by a licensed Occupational Therapist
Medical Doctors (MDs)
Doctors of Osteopathy (DOs)
Doctors of Optometry (ODs)
Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency
Qualified Non-Physician Practitioners
Advanced Nurse Practitioners (ANPs)
Physician Assistants (PAs)
Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency.
“Qualified” personnel when directly supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met. Qualified personnel have met the educational and degree requirements of a licensed therapy professional (PT, OT, SLP), but are not required to be licensed.
Please note that unless these therapy services are performed by a “qualified” person, the services are not covered and must not be reported for Medicare payment.
The 3 major factors in therapy coverage are:
Mobilization
Education
Therapeutic exercise
The dynamic component of therapy, mobilization and patient education should predominate.
Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment symptoms.
Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care.
Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care.
Complicating factors that may influence treatment:
Type
Frequency and/or duration of treatment
Diagnoses
Patient factors
Age
Severity
Acuity
Multiple conditions
Co-morbidities
Motivation
Patient’s social circumstances
In more difficult cases, the practitioner should have documentation that will support the need for continued care that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further improvement is expected.
Medicare recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress.
Please keep in mind when the duration and intensity of rehabilitative services rendered are limited or extensive, Medicare expects the patient’s medical record to demonstrate clear medical reasonableness and necessity for all therapy services, both active and passive.
Physical Medicine and Rehabilitation (PM&R) is recommended when an assessment by a physician/ NPP /or therapist supports the need for therapy services. Documentation of signs and symptoms, and the written plan of care to incorporate treatment elements that are expected to result in improvement of these limitations in a reasonable period of time.
Physical Medicine and Rehabilitation services must be furnished on an outpatient basis and provided while the patient is or was under the care of a physician or Non-Physician Practitioner.
Other specific requirements include the following:
Medicare covers therapy services that require the skill of a trained and licensed practitioner to perform or supervise.
Medicare does not cover therapy services that do not require the skill of a trained and licensed practitioner to perform even when one of the persons in the list above performs them.
A written plan of care must have diagnoses, and long-term treatment goals consisting of: type, amount, duration, frequency of therapy services.
The plan must be established by the physician, NPP or therapist providing the services before they start.
A therapist should not alter the plan of care established or certified by the physician/NPP without documented written/verbal approval.
New or significantly modified plans of care must be certified within 30 calendar days after the initial treatment under that plan, unless delayed certification criteria are met.
If certification is obtained verbally, it must be followed by a signature within 14 days to be timely.
The plan must be certified and recertified periodically by the physician or NPP.
Recertification must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less.
Services provided concurrently by a physician, PT and OT may be covered if separate and distinct goals are documented in the treatment plans.
The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted medical, physical therapy and occupational therapy practice standards and relate directly to a written treatment plan.
There must be an expectation that the condition or level of function will improve within a reasonable (and generally predictable) time or the services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease.
It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional.
These situations include:
Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility).
Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.
Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.
Maintenance therapy after the patient has achieved therapeutic goals or, for patients who show no further meaningful progress, should become patient or caregiver directed.
For all Physical Medicine and Rehabilitation modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline.
Treatment times per session vary based upon the patient’s medical initial therapy needs and progress to date toward established goals. Treatment times per session typically will not exceed 45–60 minutes. Additional time is sometimes required for more complex and/or slow-to-respond patients. However, documentation of the exceptional circumstances must be maintained in the patient’s medical record and available upon request.
Maintenance therapy after therapeutic goals and/or rehabilitative potentials are reached is medically reasonable and necessary but is not covered. However, a qualified professional may develop a maintenance program for the patient to pursue outside of a therapy program and plan of care, generally administered and supervised by family or caregivers. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required.
Examples include:
Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease.
Instructing the patient, family member(s) or caregiver(s) in carrying out the maintenance program.
Infrequent re-evaluations required to assess the patient’s condition and adjust the program.