Page 166 - Medicare Benefit Policy Manual

A. Definitions

The following defines terms used in this section and §230:

ACTIVE PARTICIPATION of the clinician in treatment means that the clinician
personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.

ASSESSMENT is separate from evaluation, and is included in services or procedures, (it
is not separately payable). The term assessment as used in Medicare manuals related to
therapy services is distinguished from language in Current Procedural Terminology
(CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment,
which may be payable). Assessments shall be provided only by clinicians, because
assessment requires professional skill to gather data by observation and patient inquiry
and may include limited objective testing and measurement to make clinical judgments
regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's
status since the last visit/treatment day and whether the planned procedure or service
should be modified. Based on these assessment data, the professional may make
judgments about progress toward goals and/or determine that a more complete evaluation
or re-evaluation (see definitions below) is indicated. Routine weekly assessments of
expected progression in accordance with the plan are not payable as re-evaluations.

CERTIFICATION is the physician’s/nonphysician practitioner’s (NPP) approval of the
plan of care. Certification requires a dated signature on the plan of care or some other
document that indicates approval of the plan of care.

The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5, section 10
or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not
to an assistant, aide or any other personnel) providing a service within their scope of
practice and consistent with state and local law. Clinicians make clinical judgments and
are responsible for all services they are permitted to supervise. Services that require the
skills of a therapist, may be appropriately furnished by clinicians, that is, by or under the
supervision of qualified physicians/NPPs when their scope of practice, state and local
laws allow it and their personal professional training is judged by Medicare contractors as
sufficient to provide to the beneficiary skills equivalent to a therapist for that service.

COMPLEXITIES are complicating factors that may influence treatment, e.g., they may
influence the type, frequency, intensity and/or duration of treatment. Complexities may
be represented by diagnoses (ICD codes), by patient factors such as age, severity, acuity,
multiple conditions, and motivation, or by the patient’s social circumstances such as the
support of a significant other or the availability of transportation to therapy.

A DATE may be in any form (written, stamped or electronic). The date may be added to
the record in any manner and at any time, as long as the dates are accurate. If they are
different, refer to both the date a service was performed and the date the entry to the
record was made. For example, if a physician certifies a plan and fails to date it, staff
may add “Received Date” in writing or with a stamp. The received date is valid for