Section 10: Therapy Medicare Criteria for Therapy Therapy services are a critical part of the patient’s/client’s plan of care which is developed in conjunction with the patient/client, caregiver, family, and physician. The patient/client must require skilled care. • Skilled services are those which are medically reasonable to the treatment of the patient’s/client’s illness or injury. • Skilled care is care that requires the skills of a physical therapist, or a speech therapist (or ongoing care of an OT). • Therapy services may be a covered service if: o Require inherent complex service. o Requires a skilled therapist to perform the services. o Requires the supervision of a skilled therapist when the service is performed. o Services ordered by the physician and/or non-physician practitioner. Services must be reasonable and necessary for the treatment of the patient’s/client’s particular medical needs. • Amount frequency and duration of services must be reasonable. • Services must be consistent with the nature and severity of the patient’s/client’s illness or injury. • Services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient’s/client’s condition, meeting the initial assessment and reassessment standards discussed below. • Services must be provided with the expectation that: o The evaluation and reevaluation must be reasonable and necessary to be covered. o The services are necessary to establish a safe and effective program. o The condition of the patient/client will improve materially in a reasonable and generally predictable period of time. Improvement is evidenced by objective successive measurements. Therapy is not considered reasonable and necessary under this condition if: • The patient’s/client’s expected restorative potential would be insignificant in relation to the extent and duration of therapy services required to reach such potential.
