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Tips for Documenting Medical Necessity

All of the components involved in medical necessity can be daunting for you to remember, especially when performing therapy duties. However, it’s essential to meet Medicare standards regarding medical necessity. Checklists are an easy way to ensure vital tasks don’t fall through the cracks. To help with the documentation process from start to finish, we have developed a Medical Necessity Checklist.

The goal of this checklist is to help assess whether or not the services you are providing, meet the Medicare standards for medical necessities during chart review. The checklist is divided into four easy to read sections from patient to payment. Check out an overview below and download the entire checklist below.

Evidence of Skilled Services: This section includes evaluation and re-evaluation addressing specific functional problems, a treatment plan, established treatment goals, and about six other tasks. Although there are nearly one dozen tasks that must be completed, it can be easy to skip an element. Make sure to thoroughly follow all steps to ensure proper medical necessity documentation. To view the entirety of this section, you can download the entire checklist below.

Additional Evidence of Skilled Therapy: Not all of the elements in this sections are required, but they can help provide additional evidence of skilled therapy. You can complete instructions in compensatory skills, selection of devices to replace or augment function, and training of patient and family to augment treatment. The necessity of these tasks will vary from patient to patient, but can prove to be extremely beneficial for certain individuals.

Rehabilitative Therapy: This section focuses on recovery, improvement in function, and restoration of previous level of health and if possible, wellbeing. Out of the three listed tasks, only one is required to ensure medical necessity.

Maintenance Program: This final section is divided into two parts: design and delivery. The design sub-section features a skill for treatment plan design, while the delivery sub-section focuses on complexity and sophistication of therapy procedures, and skills of therapist to be performed safely. At least one delivery task is required. The maintenance program requirements can be supported by either the design or delivery requirements. Please note that maintenance program standards may not apply in CORFs. Services in CORFs must meet the Rehabilitative Therapy standards.

Download the entire checklist here.

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