Page 195 - Medicare Benefit Policy Manual

Needs of the Patient. When a service is reasonable and necessary, the patient
also needs the services. Contractors determine the patient’s needs through
knowledge of the individual patient’s condition, and any complexities that
impact that condition, as described in documentation (usually in the
evaluation, re-evaluation, and progress report). Factors that contribute to need
vary, but in general they relate to such factors as the patient’s diagnoses,
complicating factors, age, severity, time since onset/acuity, self-
efficacy/motivation, cognitive ability, prognosis, and/or medical,
psychological and social stability. Changes in objective and sometimes to
subjective measures of improvement also help establish the need for
rehabilitative services. The use of scientific evidence, obtained from
professional literature, and sequential measurements of the patient’s condition
during treatment is encouraged to support the potential for continued
improvement that may justify the patients need for rehabilitative therapy or
the patient’s need for maintenance therapy.

• Functional information included on claims as required.

The clinician is required to document in the patient’s medical record, using
the G-codes and severity modifiers used in functional reporting, the patient’s
current, projected goal, and discharge status, as reported pursuant to
functional reporting requirements for each date of service for which the
reporting is required. See section 220.4 below for details on documenting G-
code and modifiers. NOTE: Functional reporting and its associated
documentation requirements are no longer applicable for claims or medical
records for dates of service on and after January 1, 2019. See the NOTE at
the beginning of Section 220.4 for more information.

C. Evaluation/Re-Evaluation and Plan of Care

The initial evaluation, or the plan of care including an evaluation, should document the
necessity for a course of therapy through objective findings and subjective patient self-
reporting. Utilize the guidelines of the American Physical Therapy Association, the
American Occupational Therapy Association, or the American Speech-Language and
Hearing Association as guidelines, and not as policy. Only a clinician may perform an
initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a
plan of care. A clinician may include, as part of the evaluation or re-evaluation, objective
measurements or observations made by a PTA or OTA within their scope of practice, but
the clinician must actively and personally participate in the evaluation or re-evaluation.
The clinician may not merely summarize the objective findings of others or make
judgments drawn from the measurements and/or observations of others.

Documentation of the evaluation should list the conditions and complexities and, where it
is not obvious, describe the impact of the conditions and complexities on the prognosis