Page 198 - Medicare Benefit Policy Manual

o Record of a previous episode of therapy treatment from the same or
different therapy discipline in the past year.

Documentation required to indicate beneficiary health related to quality of
life, specifically,

o The beneficiary’s response to the following question of self-related
health: “At the present time, would you say that your health is
excellent, very good, fair, or poor?” If the beneficiary is unable to
respond, indicate why; and

Documentation required to indicate beneficiary social support including,
specifically,

o Where does the beneficiary live (or intend to live) at the conclusion of
this outpatient therapy episode? (e.g., private home, private apartment,
rented room, group home, board and care apartment, assisted living,
SNF), and

o Who does beneficiary live with (or intend to live with) at the
conclusion of this outpatient therapy episode? (e.g., lives alone,
spouse/significant other, child/children, other relative, unrelated
person(s), personal care attendant), and

o Does the beneficiary require this outpatient therapy plan of care in
order to return to a premorbid (or reside in a new) living environment,
and

o Does the beneficiary require this outpatient therapy plan of care in
order to reduce Activities of Daily Living (ADL) or Instrumental
Activities of Daily Living or (IADL) assistance to a premorbid level or
to reside in a new level of living environment (document prior level of
independence and current assistance needs); and

*Documentation required to indicate objective, measurable beneficiary
physical function including, e.g.,

o Functional assessment individual item and summary scores (and
comparisons to prior assessment scores) from commercially available
therapy outcomes instruments other than those listed above; or

o Functional assessment scores (and comparisons to prior assessment
scores) from tests and measurements validated in the professional
literature that are appropriate for the condition/function being
measured; or