Page 196 - Medicare Benefit Policy Manual

and/or the plan for treatment such that it is clear to the contractor who may review the
record that the services planned are appropriate for the individual.

Evaluation shall include:

• A diagnosis (where allowed by state and local law) and description of the specific
problem(s) to be evaluated and/or treated. The diagnosis should be specific and as
relevant to the problem to be treated as possible. In many cases, both a medical diagnosis
(obtained from a physician/NPP) and an impairment based treatment diagnosis related to
treatment are relevant. The treatment diagnosis may or may not be identified by the
therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a
condition description similar to the appropriate ICD code. For example the medical
diagnosis made by the physician is CVA; however, the treatment diagnosis or condition
description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for
SLP, it may be dysphagia. For PT and OT, be sure to include body part evaluated.
Include all conditions and complexities that may impact the treatment. A description
might include, for example, the premorbid function, date of onset, and current function;

• Results of one of the following four measurement instruments are
recommended, but not required:

National Outcomes Measurement System (NOMS) by the American Speech-
Language Hearing Association

Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)

Activity Measure – Post Acute Care (AM-PAC)

OPTIMAL by Cedaron through the American Physical Therapy Association

• If results of one of the four instruments above is not recorded, the record shall
contain instead the following information indicated by asterisks (*) and should
contain (but is not required to contain) all of the following, as applicable. Since
published research supports its impact on the need for treatment, information in
the following indented bullets may also be included with the results of the above
four instruments in the evaluation report at the clinician’s discretion. This
information may be incorporated into a test instrument or separately reported
within the required documentation. If it changes, update this information in the
re-evaluation, and/or treatment notes, and/or progress reports, and/or in a separate
record. When it is provided, contractors shall take this documented information
into account to determine whether services are reasonable and necessary.

Documentation supporting illness severity or complexity including, e.g.,

o Identification of other health services concurrently being provided for
this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse,