Rehabilitative therapy occurs when the skills of a therapist, (See definition of therapist in section 220 of this chapter) are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.
Skilled therapy may be needed, and improvement in a patient’s condition may occur, even where a chronic or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition. In the case of a progressive degenerative disease, for example, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel without the supervision of qualified professionals.
Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program as described below, the services will no longer be considered reasonable and necessary. Services that are not reasonable or necessary should be excluded from coverage.
Potential for Improvement Due to Treatment
. If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, therapy would not be covered because it is not considered rehabilitative or reasonable and necessary.
Improvement is evidenced by successive objective measurements whenever possible (
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individual’s illness or injury and the services are not covered.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule Uribel i...
procedure code and description 71250 - Ct thorax w/o dye - average fee payment - $180 - $190 71275 CTA chest (noncoronary) 71260 CT ...
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...
Coverage Indications, Limitations, and/or Medical Necessity This LCD describes conditions under which the coverage of nail avulsion/ex...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...