We have been hearing for years that therapy services must be reasonable and necessary.  Now, with all Medicare Part B claims over $3,700 being reviewed by RACs, MACs conducting focused Probe audits, and don’t forget about the ZPIC audits, it is even more important that therapy documentation supports medical necessity through justification of reasonable and necessary therapy services.

Did you ever look up ‘Reasonable and Necessary’ in any of the CMS manuals?  Did you find a clear explanation of ‘Reasonable and Necessary’?  If you answered ‘yes’ then you are one of the lucky ones.

Let’s break down ‘Reasonable’ and ‘Necessary’ by definition and see if that will give us more clarity.

The definition of ‘Reasonable‘ is: logical, moderate, not expensive, rational.  Agreeable to reason or sound judgment; logical; not exceeding the limit prescribed; not excessive

The definition of ‘Necessary‘ is: being essential, indispensable, or requisite; happening or existing by necessity; something necessary-required, essential, something vital

Since defining each word helps somewhat, let’s now take a look at the Medicare Benefit Policy Manual, Chapter 15 section 220.2(B) where it talks about ‘Reasonable and Necessary Therapy’.  In order for therapy to be Reasonable and Necessary, there are conditions to be met.  These conditions are:

  1. The services shall be considered under accepted standards of medical practice to be a specific & effective treatment for the patient’s condition
  2. The services shall be of a level of complexity & sophistication or the condition of the patient shall be such that the services required can be safely & effectively performed ONLY by a therapist; or under the supervision of a therapist (LPTA, COTA/L)
  3. Services furnished were of a type that could have been safely & effectively performed only by or under supervision of a qualified professional, it shall presume that such services were properly supervised when required
  4. The skills of a therapist are needed to treat the illness or injury
  5. There must be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe & effective maintenance program required in connection with a specific disease state.  Progressive degenerative disease cases- service may be intermittently necessary to determine the need for assisted equipment and/or establish a program to maximize function
  6. The amount, frequency, & duration of the services must be reasonable under accepted standards of practice

So, how do we justify medical necessity in our documentation to prove that our treatment interventions are reasonable and necessary therapy services?

GET SPECIFIC!         DOCUMENT DETAILS!               USE MEDICAL TERMINOLOGY!         DOCUMENT MUSCLES TARGETED!DOCUMENT WHY YOU ARE DOING THE INTERVENTION—WHAT IS THE FUNCTIONAL REASON WHY?

In addition, you will want to make sure:

  • the services are consistent with the nature & severity of the illness, injury, and medical needs
  • the services are specific, safe, & effective according to accepted medical practice
  • there is a reasonable expectation that observable & measurable improvement in functional ability will occur
  • the intervention can only be performed by a therapist
  • the service doesn’t just promote wellness

Documenting at the time the service is provided is essential for ensuring all components of the treatment intervention are specifically documented to support the minutes billed.