CMS Pub. 100-02, ch. 8, § 30.4.1.1

Skilled physical therapy services must meet all of the following conditions:

• The services must be directly and specifically related to an active written

treatment plan that is based upon an initial evaluation performed by a qualified

physical therapist after admission to the SNF and prior to the start of physical

therapy services in the SNF that is approved by the physician after any needed

consultation with the qualified physical therapist. In those cases where a

beneficiary is discharged during the SNF stay and later readmitted, an initial

evaluation must be performed upon readmission to the SNF, prior to the start of

physical therapy services in the SNF;

• The services must be of a level of complexity and sophistication, or the condition

of the patient must be of a nature that requires the judgment, knowledge, and

skills of a qualified physical therapist;

• The services must be provided with the expectation, based on the assessment

made by the physician of the patient’s restoration potential, that the condition of

the patient will improve materially in a reasonable and generally predictable

period of time; or, the services must be necessary for the establishment of a safe

and effective maintenance program; or, the services must require the skills of a

qualified therapist for the performance of a safe and effective maintenance

program. NOTE: See Section E. Maintenance Therapy for more guidance

regarding when skilled therapy services are necessary for the performance of a

safe and effective maintenance program.

• The services must be considered under accepted standards of medical practice to

be specific and effective treatment for the patient’s condition; and,

• The services must be reasonable and necessary for the treatment of the patient’s

condition; this includes the requirement that the amount, frequency, and duration

of the services must be reasonable.

EXAMPLE 1:

An 80-year old, previously ambulatory, post-surgical patient has been bed-bound for 1

week, and, as a result, had developed muscle atrophy, orthostatic hypotension, joint

stiffness and lower extremity edema. To the extent that the patient requires a brief period

of daily skilled physical therapy to restore lost functions, those services are reasonable

and necessary and must be documented in the medical record (see §30.2.2.1).

EXAMPLE 2:

A patient with congestive heart failure also has diabetes and previously had both legs

amputated above the knees. Consequently, the patient does not have a reasonable

potential to achieve ambulation, but still requires daily skilled physical therapy to learn

bed mobility and transferring skills, as well as functional activities at the wheelchair

level. If the patient has a reasonable potential for achieving those functions in a

reasonable period of time in view of the patient’s total condition, the physical therapy

services are reasonable and necessary and must be documented in the medical record (see

§30.2.2.1).

Physical therapy services are not reasonable and necessary and would not be covered if

the expected results are insignificant in relation to the extent and duration of physical

therapy services that would be required to achieve those results.

Some SNF inpatients do not require skilled physical therapy services but do require

services, which are routine in nature. When services can be safely and effectively

performed by supportive personnel, such as aides or nursing personnel, without the

supervision of a physical therapist, they do not constitute skilled physical therapy.

Additionally, services involving activities for the general good and welfare of the patient

(e.g., general exercises to promote overall fitness and flexibility and activities to provide

diversion or general motivation) do not constitute skilled physical therapy.