Page 194 - Medicare Benefit Policy Manual

• The patient is under the care of a physician/NPP;

Physician/NPP care shall be documented by physician/NPP certification
(approval) of the plan of care; and

Although not required, other evidence of physician/NPP involvement in the
patient’s care may include, for example: order/referral, conference, team
meeting notes, and correspondence.

• Services require the skills of a therapist.

Services must not only be provided by the qualified professional or qualified
personnel, but they must require, for example, the expertise, knowledge,
clinical judgment, decision making and abilities of a therapist that assistants,
qualified personnel, caretakers or the patient cannot provide independently. A
clinician may not merely supervise, but must apply the skills of a therapist by
actively participating in the treatment of the patient during each progress
report period. In addition, a therapist’s skills may be documented, for
example, by the clinician’s descriptions of their skilled treatment, the changes
made to the treatment due to a clinician’s assessment of the patient’s needs on
a particular treatment day or changes due to progress the clinician judged
sufficient to modify the treatment toward the next more complex or difficult
task.

• Services are of appropriate type, frequency, intensity and duration for the
individual needs of the patient.

Documentation should establish the variables that influence the patient’s
condition, especially those factors that influence the clinician’s decision to
provide more services than are typical for the individual’s condition.

Clinicians and contractors shall determine typical services using published
professional literature and professional guidelines. The fact that services are
typically billed is not necessarily evidence that the services are typically
appropriate. Services that exceed those typically billed should be carefully
documented to justify their necessity, but are payable if the individual patient
benefits from medically necessary services. Also, some services or episodes
of treatment should be less than those typically billed, when the individual
patient reaches goals sooner than is typical.

Documentation should establish through objective measurements that the
patient is making progress toward goals. Note that regression and plateaus
can happen during treatment. It is recommended that the reasons for lack of
progress be noted and the justification for continued treatment be documented
if treatment continues after regression or plateaus.