When it comes to getting accurate reimbursement for physical therapy services, a lot of parameters are involved in it. That includes qualified clinicians; skilled level of care; proving medical necessity; and documentation when additional medical necessary services are required. Medical records must support medical necessity of therapy services provided e.g., Are the services appropriate for the patient’s condition, and do the services require the skills and knowledge of a qualified clinician? Getting reimbursed for physical therapy services is challenging but not difficult, focussing on key areas will ensure accurate insurance reimbursements. All the key areas for accurately getting reimbursed for physical therapy services for government and private insurance are discussed below.
Therapy services must be provided by a qualified clinician i.e., physician, non-physician practitioner (NPP), therapist, or speech-language pathologist (SLP). Treatment services may also be provided by an appropriately supervised physical therapy (PT) or occupational therapy (OT) assistant. Services provided by a therapy aide with or without qualified clinician supervision are not reimbursable in any therapy setting.
Skilled Level of Care
Skill is a level of expertise acquired through specialized training not attained by the general population. While a patient’s medical condition is a valid factor in deciding if skilled therapy services are needed, a patient’s diagnosis or prognosis is never the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel after sufficient training.
To demonstrate that services are at a skilled level of care, the medical record must support that the expertise and knowledge of a qualified clinician were necessary and provided. Documentation needs to clearly indicate the clinician’s unique professional contribution to the therapy services e.g., Why did the patient require professional treatment, education, or training? What specialized treatment, education or training did the clinician actually provide? How did the patient benefit from the specialized knowledge applied by the clinician?
Skilled land and water-based therapy programs require that the patient have direct one-on-one contact with the qualified clinician throughout the procedure. The services of a qualified clinician cannot be billed for supervising a patient that is independently completing an exercise program. Additionally, ongoing repetitive exercises that do not demonstrate the need for continued hands-on involvement and/or teaching by the qualified clinician would not be considered to be at a skilled level of care. Documentation must support that the therapy sessions are at a level of complexity that requires ongoing qualified clinician input.
Services must be under accepted standards of medical practice and considered to be a specific and effective treatment for the patient’s condition. The amount, frequency, and duration of the services planned and provided must be reasonable. Services must be necessary for the treatment of the patient’s condition: The medical record must clearly describe the patient’s condition before, during, and after the therapy episode to support that the patient significantly benefited from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patient’s condition at the start of treatment. Documentation of comparable objective/functional measures plays a key role in demonstrating medical necessity.
Insurance carriers reimburse for the development of a medically necessary individualized maintenance program to maximize and retain the patient’s functional status achieved with therapy services. It also assures the patient safety within their home environment and trains the patient and/or caregiver in the maintenance activities. Insurance carriers don’t reimburse for carrying out maintenance activities when the activities do not require the skills of a qualified clinician i.e., the level of complexity and sophistication of the activities do not require the performance and/or supervision of a therapist. Or the condition of the patient is such that the services do not require the performance and/or supervision of a therapist. It is anticipated that once the maintenance program is established, updates to the program will be necessary on an infrequent basis.
Documentation for Medical Necessity
When additional medical necessary services are required for the same medical condition, a thorough initial evaluation should be completed for the patient who was previously discharged. Documentation for maintenance program revisions must support that any additional therapy services require the performance and/or supervision of a qualified therapist due to the complexity/sophistication of the required procedures and/or the condition of the patient. The documentation must clearly indicate why a revision of the maintenance program is necessary and what specific revision(s) are needed. Key documentation components include:
- Was the patient/caregiver compliant with their previously established maintenance program?
- Was the patient unable to complete the maintenance program? Why?
- Are there any new significant medical and/or functional issues noted since discharge from prior therapy that necessitate revision of the maintenance program?
Legion Health Care Solutions is a leading medical billing company that can assist you in revenue cycle functions for your practice. Our billing and coding expertise will help you in getting reimbursed for physical therapy services delivered. To know more about our physical therapy services, you can call us at 727-475-1834 or email us at firstname.lastname@example.org