Learning Objectives
Our objectives for today are to discuss when rehab services meet Medicare coverage criteria. We are going to talk about the guidelines for writing measurable short and long-term goals, and then we will talk about how we can justify our services. I have pared down this particular presentation to those questions that seem to be coming up over and over again; goals and documenting skill. There are a whole host of other things that go into our documentation. We are going to focus on these for today.
General Information
Let’s start with some general information. The reality is that the documentation we provide in the clinical record is our only evidence that our therapy services meet the basic criteria from Medicare, and that is that it is medically necessary, meaning that the patient requires these particular services whatever they are. The services require the skills of a therapist. No one else can provide that service; only a therapist can. The services were provided with physician’s orders, and on top of that, we are following the physician's orders. If they say five times a week, we are delivering five times a week. Finally, the services that were provided support the services billed. You will hear me say this again, but only those services that are clearly documented, reflected in the medical record, and justified in the medical record will be eligible for payment.
Keep in mind that there used to be another requirement that said that progress was demonstrated. This has now been removed. It is no longer an element required for skilled care and all of the Medicare documents have been updated to reflect that. However, if we do not show progress, if we truly are skilling someone only for maintenance, then our documentation showing skill is all that much more critical.
What is Medical Necessity?
The key for coverage is that the patient needs the services and those services can only be provided by a therapist. These services could be restorative in nature, where we truly are trying to get that patient back to a better level of function or back to their home environment. It could be to maintain the patient's current status, which is obviously maintenance therapy, or it could be used to prevent or slow further deterioration, which is again a type of maintenance therapy. Examples might be providing a splint or modifying wheelchair seating. Keep in mind that the determination of whether or not someone is skilled or if it is medically necessary needs to be based on the patient's condition. Without looking at if the condition is acute, chronic, long-standing, terminal, or expected to last a long time; we truly just have to look at the clinical picture of the patient today and how that patient is presenting.
Remember that all services must be directly and specifically related to an active treatment plan that is designed to treat the patient and is also approved by the physician. You will hear me say this at least 100 times. It has to be a level of complexity that those services can only be safely performed by a qualified therapist or under a qualified therapist’s supervision. Remember before the Jimmo versus Sebelius case; Sebelius refers to Kathleen Sibelius, the previous on Secretary of Health in the Department Health and Human Services. Before that, there was a statement that the patient had to have an improvement in a materially and reasonable period of time, and again that has been removed.
