Pre-Claim Review Non-Affirmations: Therapy

Below are the top reasons of non-affirmations for therapy services:

• Documentation submitted does not include measurable physical therapy treatment goals that are related to the patient's illness/injury/impairment
• Documentation submitted does not support that physical therapy services are reasonable and necessary and at a level of complexity which requires the skills of a qualified therapist
• Documentation submitted does not include specific therapy goals
• An order for therapy services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services

Ensure that the documentation submitted supports the medical necessity of the therapy services. These services must be:

• Reasonable and necessary for the treatment of the patient’s illness or injury
• Reasonable and necessary for the restoration of maintenance of function  affected by the patient’s illness or injury
• The inherent complexity of the care is such that it can be performed safely and effectively only by or under the general supervision of a skilled therapist and require the skills of a therapist
• Include the Initial Therapy Evaluation, current therapy re-evaluation(s) for episode under review and the previous therapy re-evaluation(s) 

The physician and/or physical therapist's evaluation/re-evaluation assess the area for which physical therapy treatment is being planned. It must be completed prior to beginning therapy. Evaluations must contain the following information:

1. Reason for referral
2. Diagnosis/condition being treated
3. Past level of function (be specific)
4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress
5. Current level of function
6. Objective measurements such as strength, ROM, pain, ADL level, or edema
7. Treatment techniques/modalities selected for treating current illness or injury
8. Limitations which may influence the length of treatment
9. Short- and/or long-term goals stated in objective measurable terms, and their expected date of accomplishment
10. Frequency and duration of therapy

The American Physical Therapy Association recommends the goals include the following components:

1. Identification of the person
2. Description of the movement or activity
3. A connection of the movement/activity to a specific function
4. Specific conditions in which the activity will be performed
5. Factors for measuring the outcome
6. Time frame for achieving the goal

The documentation of the beneficiary encounter should relate back to the goals. Willard and Spackman recommend the RUMBA test:

1. Relevant: functional goals and achievement; patient-specific
2. Understandable: legible and avoid jargon; use of accepted standard terminology
3. Measurable: includes frequency and duration, how long it occurred or how many times
4. Behavioral: measurable occurrences
5. Achievable: reasonable

A complete therapy order must include:

1. Discipline to render services (specific professional who is to perform the care)
2. Frequency of services (number of visits to be rendered stated in days, weeks or months)
3. Duration of services (length of time the services are to be rendered)
4. Treatment or service being provided and the order is signed and dated by the physician prior to billing the final claim to the contractor (type of care or service to be rendered by the discipline)

An order that states “eval and treat” must be followed by an order with in the information listed above.

References

• Guide to Physical Therapist Practice. Rev ed. Alexandria, VA: American Physical Therapy Association;1999
• Willard, Helen S.Schell, Barbara A. Boyt. (Eds.) (2014) Willard & Spackman's Occupational Therapy. Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins