Policy Statement
[PROVIDER] is committed to providing quality therapy services and to providing only those therapy services that are reasonable and necessary to a resident’s appropriate care, and consistent with government and third-party payor coverage guidelines and the criteria set forth below.
Physical Therapy Services
Medicare: Suggested Elements
Providers may wish to include the following suggested elements in their corporate compliance policy.
Physical therapy services provided to Medicare residents by [PROVIDER] must:
- Relate directly and specifically to an active written treatment regimen established by the resident’s physician after any needed consultation with the qualified physical therapist;
- Be reasonable and necessary to the treatment of the resident’s illness or injury;
- Be of such a level of complexity and sophistication, or the condition of the resident must be such, that the services required can be safely and effectively performed only by a qualified physical therapist or under his or her supervision. Services not requiring the performance or supervision of a physical therapist are not considered reasonable or necessary physical therapy services, even if they are performed or supervised by a physical therapist;
- Be provided pursuant to an expectation that the condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment made by the physician, or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state; and
- Be reasonable in terms of amount, frequency, and duration.
Medicaid: Suggested Elements
Physical therapy services, including all necessary supplies and equipment, provided to Medicaid residents by [PROVIDER] must:
- Be prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law; and
- Be provided to a recipient by or under the direction of a qualified physical therapist.
Speech Therapy Services
Medicare: Suggested Elements
Speech therapy services provided to Medicare residents by [PROVIDER] must:
- Be reasonable and necessary to the treatment of the resident’s illness or injury;
- Relate directly and specifically to a written treatment regimen established by the resident’s physician after any needed consultation with the qualified speech pathologist;
- Be considered under accepted standards of practice to be a specific and effective treatment for the resident’s condition;
- Be of such a level of complexity and sophistication, or the resident’s condition must be such, that the services required can be safely and effectively performed only by or under the supervision of a qualified speech pathologist;
- Be provided pursuant to an expectation that the resident’s condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment by the physician, or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state; and
- Be reasonable in terms of amount, frequency, and duration under accepted standards of practice.
Medicaid: Suggest Elements
Speech therapy services, including the necessary supplies and equipment, provided to Medicaid residents by [PROVIDER] must:
- Be prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law; and
- Be provided to a recipient by or under the direction of a speech pathologist or audiologist.
Occupational Therapy Services
Medicare: Suggested Elements
Occupational therapy services provided to Medicare residents by [PROVIDER] must:
- Be prescribed by a physician;
- Be performed by a qualified occupational therapist or a qualified occupational therapy assistant under the general supervision of a qualified occupational therapist;
- Be reasonable and necessary for the treatment of the resident’s illness or injury; and
- Be provided pursuant to an expectation that the therapy will result in a significant practicable improvement in the resident’s level of functioning within a reasonable period of time.
Medicaid: Suggested Elements
Occupational therapy services, including all necessary supplies and equipment, provided to Medicaid residents by [PROVIDER] must:
- Be prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law; and
- Be provided to a recipient by or under the direction of a qualified occupational therapist.
Outpatient Physical, Occupational, and Speech Therapy Services
Outpatient physical, occupational, and/or speech therapy services provided to Medicare residents by [PROVIDER] must:
- Be provided only to residents who were or are under the care of a physician. The resident’s clinical record must reflect that a physician has seen the resident at least every 30 days;
- Be provided pursuant to a written plan established by a physician, physical therapist; occupational therapist, or speech pathologist for furnishing such services; and which periodically is reviewed by the physician;
- Be required by the resident; and
- Be recertified by the resident’s physician at least once every 30 days if the services continue over a period of time.