In a world of constant chatter, revolving news streams, and search for the latest and greatest viral trend, there is a skill to shutting it all out and going back to the basics. 

In the realm of rehab that often means appreciating what makes our services unique and in the regulatory sense “skilled.”

Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. 

Let’s start with some definitions and guidance from Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services.

We are clinicians, after all, who provide care to complex patients daily so how about we start there!

The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5, section 10 or section 20, to refer to only a physician, non-physician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law.

OK, so what are clinicians, providing care under their scope of practice, responsible for?  

Clinicians make clinical judgments and are responsible for all services they are permitted to supervise. Services that require the skills of a therapist may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary skills equivalent to a therapist for that service.

Now on to complexities. As you read below, I also want you to consider: Does the care you provide daily evidence complexity in the interventions you use and the documentation you complete.

COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment. Complexities may be represented by diagnoses (ICD codes), by patient factors such as age, severity, acuity, multiple conditions and motivation, or by the patient’s social circumstances, such as the support of a significant other or the availability of transportation to therapy.

So yes, you are thinking, I see complex folks every single day. Much of the data needed to appreciate complexity starts with my hands-on evaluation. How is that defined per Medicare?

EVALUATION is defined as a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted such as for a new diagnosis or when a condition is treated in a new setting. 

These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.

Great! Now that I have completed the evaluation I am good to go, right?

Hold on… Let us not forget the requirement for physician certification.

CERTIFICATION is the physician’s/non-physician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

Now, on to intervention. 

The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition. Acceptable practices for therapy services are found in:

  • Medicare manuals (such as this manual and Publications 100-03 and 100-04),
  • Contractors Local Coverage Determinations (LCDs and NCDs are available on the Medicare Coverage Database), and
  • Guidelines and literature of the professions of physical therapy, occupational therapy and speech-language pathology.

The key takeaway here: Know the rules that govern practice not only in the literature but also in the region of the nation where you are providing care.

The next step is showing the uniqueness of your care. 

The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. 

Furthermore, services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional. Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. 

What about diagnosis or condition? How does this impact skill? 

While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel. 

What considerations should be given to how often/long I see a patient?

The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines.

Back to the basics… time to appreciate and show your skill and better care for those we serve daily. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected]  

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.