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How to Document Medical Necessity for Therapy Care

Although therapy is no longer a financial driver under the Patient-Driven Groupings Model (PDGM), it remains crucial for skilled therapy services to meet the criteria for medical necessity in order to lessen the risk of payment reduction.

All visits performed for therapy are subject to evaluation by the Centers for Medicare & Medicaid Services (CMS) based on medical necessity. Unfortunately, inadequate therapy reassessment documentation may result in period 2 dropping to a Low Utilization Payment Adjustment (LUPA) or a full payment denial.

The key is comprehensive and consistent documentation – from initial evaluation to subsequent therapy visits – that clearly demonstrates progress completion of necessary therapy goals. For instance, therapy medical necessity and goals established in the therapy evaluation should be substantiated in the plan of care. Moreover, patient progress towards the initial goals should be described in detail on subsequent visit notes.

Therapy Documentation Guidelines

1. Therapy Evaluation and Plan of Care (POC)

To develop a comprehensive and reasonable Plan of Care (POC), make detailed documentation of all the aspects that affect the patient’s functional status. To do so, document the following upon patient evaluation:

  • Reason for referral to home health
  • The diagnosis or condition to be treated
  • Past and current functional level
  • Baseline physical and cognitive status evaluation
  • Current objective measurements for range of motion (ROM), level of assistance, use of specific assistive devices, strength measurement, distance, timed up and go (TUG) test, Tinetti, etc., and any other contributing factors that may influence treatments
  • Treatments relevant to the current diagnosis, illness, or injury
  • Patient and caregiver goals for the episode of care
2. Visit Notes

To paint the overall picture of the patient’s physical progression from visit to visit, the following are key components to cover in the therapy documentation on every patient encounter.

  • A physical exam pertinent to the day’s visit and any relevant history, including the patient’s response or any changes since the previous visit
  • Skilled therapy performed on the current visit
  • The patient/caregiver’s response to the skilled service provided
  • Objective measurements of physical ability based on the treatment provided
  • Documentation toward goals achieved regarding ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
  • A detailed explanation supporting the necessity for further therapy services based on the outcomes of the visit and the progress thus far
  • Any other documentation necessary that details the necessity for home health therapy services including homebound status
  • It is also important to focus on documenting what the patient is specifically capable of such as, “the patient is able to perform a safe transfer from bed to commode with SBA and use of FWW.”  Avoid using general statements such as, “the patient is doing well” or “the patient’s mobility is improving”.

Setting Specific and Measurable Goals
It is important to indicate the duration of short- and long-term goals so that throughout the certification period, it is easier to track progress of each visit. Here are some things to include:

  • Data on admission of current state of ROM and the goal to be attained
  • Data on admission of current state of strength (i.e., 2+/5) and the goal to be attained
  • Data on admission of current balance score using method chosen by the agency and the goal to be attained
  • The specific type of assistive device currently used and the goal for the assistive device to be used for ambulation, transfers, and stairs (Wheelchair, RW, 4WW, cane, etc.)
  • The type of assistance needed (Max, Mod, Min, CGA, SBA, Mod I, I) for bed mobility, transfers, ambulation (if able, specify for even/uneven ground and indoor/outdoor ambulation), stairs on admission, and the goals to be attained
  • Data on admission of current state of balance and safety (TUG, Tinetti scores) and the goal to be attained
  • Any other pertinent goals specific to the patient’s ability to remain safely in the home or be able to leave the home safely
3. Therapy Re-evaluation

For each therapy discipline involved in the patient case (as indicated in the POC), a reassessment must be performed and documented by a licensed therapist (not an assistant) at least once every 30 days. In addition to the initial evaluation, a comprehensive evaluation should be performed to reassess and document the patient’s adaptation of goals or support medical necessity for the continuation of services. Make sure to take note of the following substantial data and information:

  • Data obtained from the previous evaluation regarding objective measurements for ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
  • Data obtained from the current day evaluation regarding objective measurements for ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
  • Any new information that may assist in determining the need for continued therapy, a change in goals based on the ability or inability to attain them (e.g. a patient had an injury and was previously medically prescribed as NWB and is now FWB), or a need for discontinuation of services (e.g. a patient that has been referred to outpatient therapy or perhaps the patient has moved out of the agencies service area)
  • Any other physiological or cognitive change in condition that may affect the overall outcome for the patient

Reviewing Documentation to Ensure Compliance

The key to establishing and executing a valid therapy care plan is to develop and reassess therapy goals and thoroughly document functional levels and the patient’s progress towards set goals. 

Your QA review program plays a significant role in ensuring all these important points are reflected in the documentation. Essentially, your QA team should help you make sure that the following objectives are accomplished:

  1. Therapy goals set are necessary, reasonable, and coincide with the patient’s functional status.
  2. Subsequent therapy visit documentation describes the patient’s progression towards initial goals.
  3. Appropriate comparison of original goals with the patient’s current status on the 30-day functional assessment.

Therapy medical necessity relies heavily on documentation. Thus, it is important to have clear evidence of successful home health therapy services by way of improving your clinicians’ documentation skills, while being reinforced by an efficient QA review program. A complete, substantial, and data-driven view of the patient case is a certain strategy to attain medical necessity compliance, and therefore, deliver effective patient care.