Page 192 - Medicare Benefit Policy Manual

Maintenance program services that do not meet the criteria of this section are not
reasonable or necessary and are not covered under §1862(a)(1)(A) of the Act.

The maintenance program provisions outlined in this section do not apply to the PT, OT,
or SLP services furnished in a comprehensive outpatient rehabilitation facility (CORF)
because the statute specifies that CORF services are rehabilitative.

220.3 - Documentation Requirements for Therapy Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

A. General

To be payable, the medical record and the information on the claim form must
consistently and accurately report covered therapy services, as documented in the medical
record. Documentation must be legible, relevant and sufficient to justify the services
billed. In general, services must be covered therapy services provided according to
Medicare requirements. Medicare requires that the services billed be supported by
documentation that justifies payment. Documentation must comply with all requirements
applicable to Medicare claims.

The documentation guidelines in sections 220 and 230 of this chapter identify the
minimal expectations of documentation by providers or suppliers or beneficiaries
submitting claims for payment of therapy services to the Medicare program. State or
local laws and policies, or the policies or professional guidelines of the relevant
profession, the practice, or the facility may be more stringent. It is encouraged but not
required that narratives that specifically justify the medical necessity of services be
included in order to support approval when those services are reviewed. (See also section
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services)

Contractors shall consider the entire record when reviewing claims for medical necessity
so that the absence of an individual item of documentation does not negate the medical
necessity of a service when the documentation as a whole indicates the service is
necessary. Services are medically necessary if the documentation indicates they meet the
requirements for medical necessity including that they are skilled, rehabilitative services,
provided by clinicians (or qualified professionals when appropriate) with the approval of
a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in
rehabilitation of function).

B. Documentation Required

List of required documentation. These types of documentation of therapy services are
expected to be submitted in response to any requests for documentation, unless the
contractor requests otherwise. The timelines are minimum requirements for Medicare
payment. Document as often as the clinician’s judgment dictates but no less than the
frequency required in Medicare policy: