CMS Pub. 100-02, ch. 8, § 30.4.1.2

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.