Application of Guidelines

30.4.1.2 - Application of Guidelines (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3132.3.A.2, SNF-214.3.A.2 Some of the more common skilled physical therapy modalities and procedures are: A. Assessment The skills of a physical therapist are required for the ongoing assessment of a patient’s rehabilitation needs and potential. Skilled rehabilitation services concurrent with the management of a patient’s care plan include tests and measurements of range of motion, strength, balance, coordination, endurance, and functional ability. B. Therapeutic Exercises Therapeutic exercises, which must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient. C. Gait Training Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality often require the skills of a qualified physical therapist. Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking can be appropriately provided by supportive personnel, e.g., aides or nursing personnel, and would not necessarily require the skills of a physical therapist. Thus, such services are not inherently skilled. However, see §30.2.2. for the specific circumstances in which an ordinarily nonskilled service can nevertheless be considered skilled. Documentation of the patient’s condition in the medical record must describe the circumstances which delineate the need for skilled rather than unskilled services during gait training. D. Range of Motion Only the qualified physical therapist may perform range of motion tests and, therefore, such tests are skilled physical therapy. Range of motion exercises constitute skilled physical therapy only if they are part of active treatment for a specific disease state which has resulted in a loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost, the degree to be restored and the impact on mobility and/or function). Generally, range of motion exercises which are not related to the restoration of a specific loss of function may be provided safely by supportive personnel, such as aides or nursing personnel, and as such would not necessarily require the skills of a physical therapist. Passive exercises to maintain range of motion in paralyzed extremities that can be carried out by aides or nursing personnel would not be considered skilled care. However, see §30.2.2. for the specific circumstances in which an ordinarily nonskilled service can nevertheless be considered skilled. Documentation of the patient’s condition in the medical record must describe the circumstances which delineate the need for skilled rather than unskilled services during range of motion training. E. Maintenance Therapy Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) If all other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non- therapists, including unskilled caregivers, such maintenance services do not constitute a covered level of care. A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct supervision of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct supervision of a therapist, the service cannot be regarded as a skilled therapy service even when a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service. However, even though it would not otherwise require the skills of a therapist, the performance of a maintenance program may nevertheless require such skills under certain circumstances. Specifically, skilled therapy services are necessary for the performance of a safe and effective maintenance program only when (a) the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled; or (b) the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedure. If the specialized knowledge and judgment of a qualified therapist are required, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are considered skilled therapy services, to the extent provided by regulation. EXAMPLE: A patient with Parkinson’s disease may require the services of a physical therapist to determine the type of exercises that are required to maintain his present level of function. The initial evaluation of the patient’s needs, the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record (see §30.2.2.1). While a patient is receiving a skilled physical therapy program, the physical therapist should regularly reevaluate the patient’s condition and adjust any exercise program the patient is expected to carry out independently or with the aid of supportive personnel to maintain the function being restored. Consequently, by the time it is determined that no further skilled therapy services are needed, i.e., by the end of the last skilled session, the physical therapist will have already designed any maintenance program required and instructed the patient or supportive personnel in the carrying out of the program. F. Ultrasound, Shortwave, and Microwave Diathermy Treatments These modalities must always be performed by or under the supervision of a qualified physical therapist. G. Hot Packs, Infra-Red Treatments, Paraffin Baths, and Whirlpool Baths Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist. However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. There must be clear documentation in the medical record of the special medical complications that describe the need for the skilled therapy provided by the therapist.