CMS Pub. 100-02, ch. 15, § 220.2

Services

(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

References: Pub. 100-08, chapter 13, §13.5.1,

42CFR410.59,

42CFR410.60

A. General

To be covered, services must be skilled therapy services as described in this chapter and

be rendered under the conditions specified. Services provided by professionals or

personnel who do not meet the qualification standards, and services by qualified people

that are not appropriate to the setting or conditions are unskilled services. 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 or general supervision, as applicable, of a

therapist. If a service can be self-administered or safely and effectively furnished by an

unskilled person, without the direct or general supervision, as applicable, of a therapist,

the service cannot be regarded as a skilled therapy service even though a therapist

actually furnishes the service. Similarly, the unavailability of a competent person to

provide a non-skilled service, notwithstanding the importance of the service to the

patient, does not make it a skilled service when a therapist furnishes the service.

Skilled therapy services may be necessary to improve a patient’s current condition, to

maintain the patient’s current condition, or to prevent or slow further deterioration of the

patient’s condition. For further information see 220.2, subsections C (Rehabilitative

Services) and subsection D (Maintenance Programs).

Services that do not meet the requirements for covered therapy services in Medicare

manuals are not payable using codes and descriptions as therapy services. For example,

services related to activities for the general good and welfare of patients, e.g., general

exercises to promote overall fitness and flexibility and activities to provide diversion or

general motivation, do not constitute therapy services for Medicare purposes. Also,

services not provided under a therapy plan of care, or provided by staff who are not

qualified or appropriately supervised, are not payable therapy services.

Examples of coverage policies that apply to all outpatient therapy claims are in this

chapter, in Pub. 100-04, chapter 5, and Pub. 100-08, chapter 13. Some policies in other

manuals are repeated here for emphasis and clarification. Further details on documenting

reasonable and necessary services are found in section 220.3 of this chapter.

B. Reasonable and Necessary

To be considered reasonable and necessary, each of the following conditions must be

met. (This is a representative list of required conditions and does not fully describe

reasonable and necessary services. See the remainder of this section and associated

information in section 230.)

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

be a specific and effective treatment for the patient’s condition. Acceptable

practices for therapy services are found in:

o Medicare manuals (such as this manual and Publications 100-03 and 100-04),

o Contractors Local Coverage Determinations (LCDs and NCDs are available

on the Medicare Coverage Database: http://www.cms.hhs.gov/mcd, and

o Guidelines and literature of the professions of physical therapy, occupational

therapy and speech-language pathology.

• The services shall be of such a level of complexity and sophistication or the

condition of the patient shall be such that the services required can be safely

and effectively performed only by a therapist, or in the case of physical

therapy and occupational therapy by or under the supervision of a therapist.

Services that do not require the performance or supervision of a therapist are

not skilled and are not considered reasonable or necessary therapy services,

even if they are performed or supervised by a qualified professional.

Medicare coverage does not turn on the presence or absence of a beneficiary’s

potential for improvement from the therapy, but rather on the beneficiary’s

need for skilled care. (For additional guidance, see subsection D below

related to Maintenance Programs.)

• If the contractor determines the services furnished were of a type that could

have been safely and effectively performed only by or under the supervision

of such a qualified professional, the contractor shall presume that such

services were properly supervised when required. However, this presumption

is rebuttable and, if in the course of processing a claim, the contractor finds

that services were not furnished under proper supervision, it shall deny the

claim and bring this matter to the attention of the Division of Survey and

Certification of the Regional Office.

• While a beneficiary’s particular medical condition is a valid factor in deciding

if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis

cannot be the sole factor in deciding that a service is or is not skilled. The key

issue is whether the skills of a therapist are needed to treat the illness or

injury, or whether the services can be carried out by nonskilled personnel. See

items C and D for descriptions of covered skilled services; and

• The amount, frequency, and duration of the services must be reasonable under

accepted standards of practice. The contractor shall consult local

professionals or the state or national therapy associations in the development

of any utilization guidelines.

NOTE: Claims for therapy services denied because they are not considered reasonable

and necessary under §1862(a)(1)(A) of the Act and, for services furnished on or after

January 1, 2013, those denied as a result of application of the therapy caps under

§1833(g)(1) or (g)(3) are subject to consideration under the waiver of liability provision

in §1879 of the Act. Although Section 50202 of the Bipartisan Budget Act (BBA) of

2018 repealed the therapy caps and its exceptions process effective January 1, 2018, it did

not change provider liability procedures which first became effective January 1, 2013.

Section 1833(g)(8) of the Social Security Act (as redesignated by the BBA of 2018)

continues to provide limitation of liability (LOL) protections to beneficiaries receiving

outpatient therapy services on or after January 1, 2013, when services are denied for

certain reasons, including failure to include a necessary −KX modifier. (Section 1879

provides LOL protections for reasonable and necessary denials more generally.) Under

section §1833(g)(8), the therapist or therapy provider is financially liable for the cost of

therapy services provided to a beneficiary above the threshold amount when Medicare

denies payment for failure to use the −KX modifier to indicate that the services are

medically necessary as justified by documentation in the medical record. In order for the

therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid

ABN, Form CMS-R-131. For more information, see the Therapy Services webpage at:

https://www.cms.gov/Medicare/Billing/TherapyServices/index.html for the Advance

Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ)

document that was posted to reflect the changes of the Bipartisan Budget Act of 2018.

Please find the document titled: “August 2018 ABN FAQs” in the Downloads section on

this webpage.

C. Rehabilitative Therapy

Rehabilitative therapy includes services designed to address recovery or improvement in

function and, when possible, restoration to a previous level of health and well-being.

Therefore, evaluation, re-evaluation and assessment documented in the Progress Report

should describe objective measurements which, when compared, show improvements in

function, decrease in severity or rationalization for an optimistic outlook to justify

continued treatment. Improvement is evidenced by successive objective measurements

whenever possible (see objective measurement and other instruments for evaluation in

the §220.3.C of this chapter). If an individual’s expected rehabilitation potential is

insignificant in relation to the extent and duration of therapy services required to achieve

such potential, rehabilitative therapy is not reasonable and necessary.

Rehabilitative therapy services are skilled procedures that may include but are not limited

to:

• Evaluations and reevaluations;

• Establishment of treatment goals specific to the patient’s disability or

dysfunction and designed to specifically address each problem identified in

the evaluation;

• Design of a plan of care addressing the patient’s disorder, including

establishment of procedures to obtain goals, determining the frequency and

intensity of treatment;

• Continued assessment and analysis during implementation of the services at

regular intervals;

• Instruction leading to establishment of compensatory skills;

• Selection of devices to replace or augment a function (e.g., for use as an

alternative communication system and short-term training on use of the device

or system); and

• Training of patient and family to augment rehabilitative treatment. Training

of staff and family should be ongoing throughout treatment and instructions

modified intermittently as the patient’s status changes.

Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a

recognized therapy service whose goal is improvement of an impairment or functional

limitation. (See definition of therapist in section 220.A of this chapter.) Services that can

be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without

the supervision of therapists are not rehabilitative therapy services.

Rehabilitative therapy may be needed, and improvement in a patient’s condition may

occur, even when a chronic, progressive, degenerative, or terminal condition exists. For

example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety

dependence requiring skilled therapy services. The fact that full or partial recovery is not

possible does not necessarily mean that skilled therapy is not needed to improve the

patient’s condition or to maximize his/her functional abilities. The deciding factors are

always whether the services are considered reasonable, effective treatments for the

patient’s condition and require the skills of a therapist, or whether they can be safely and

effectively carried out by nonskilled personnel.

Rehabilitative therapy is not required to effect improvement or restoration of function

when a patient suffers a transient and easily reversible loss or reduction of function (e.g.,

temporary and generalized weakness, which may follow a brief period of bed rest

following surgery) that could reasonably be expected to improve spontaneously as the

patient gradually resumes normal activities. Therapy furnished in such situations is not

considered reasonable and necessary for the treatment of the individual’s illness or injury

and the services are not covered.

If at any point in the treatment of an illness it is determined that the treatment is not

rehabilitative, the services will no longer be considered reasonable and necessary under

this section. (See Section 220.2 D for additional covered therapy benefits under

maintenance programs). Services that are not reasonable or necessary are excluded from

coverage under §1862(a)(1)(A) of the Act.

D. Maintenance Programs

Skilled therapy services that do not meet the criteria for rehabilitative therapy may be

covered in certain circumstances as maintenance therapy under a maintenance program.

The goals of a maintenance program would be, for example, to maintain functional status

or to prevent or slow further deterioration in function.

Coverage for skilled therapy services related to a reasonable and necessary maintenance

program is available in the following circumstances:

• Establishment or design of maintenance programs. If the specialized skill,

knowledge and judgment of a qualified therapist are required to establish or

design a maintenance program to maintain the patient’s current condition or to

prevent or slow further deterioration, the establishment or design of a

maintenance program by a qualified therapist is covered. If skilled therapy

services by a qualified therapist are needed to instruct the patient or appropriate

caregiver regarding the maintenance program, such instruction is covered. If

skilled therapy services are needed for periodic reevaluations or reassessments of

the maintenance program, such periodic reevaluations or reassessments are

covered.

• Delivery of maintenance programs. Once a maintenance program is

established, coverage of therapy services to carry out a maintenance program

turns on the beneficiary’s need for skilled care. A maintenance program can

generally be performed by the beneficiary alone or with the assistance of a family

member, caregiver or unskilled personnel. In such situations, coverage is not

provided. However, 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 safe and effective services in a maintenance program. Such

skilled care is necessary for the performance of a safe and effective maintenance

program only when (a) the therapy procedures required to maintain the patient’s

current function or to prevent or slow further deterioration are of such complexity

and sophistication that the skills of a qualified therapist are required to furnish the

therapy procedure or (b) the particular patient’s special medical complications

require the skills of a qualified therapist to furnish a therapy service required to

maintain the patient’s current function or to prevent or slow further deterioration,

even if the skills of a therapist are not ordinarily needed to perform such therapy

procedures. Unlike coverage for rehabilitation therapy, coverage of therapy

services to carry out a maintenance program does not depend on the presence or

absence of the patient’s potential for improvement from the therapy.

The deciding factors are always whether the services are considered reasonable, effective

treatments for the patient’s condition and require the skills of a therapist, or whether they

can be safely and effectively carried out by nonskilled personnel or caregivers.

The examples that follow are intended to provide illustrations of how coverage

determinations are made. These examples are not intended to include all possible

situations in which coverage is provided or all reasons for denying coverage. Rather they

are intended only to show how to analyze the coverage issue.

Example #1 reflects a typical outpatient scenario in which a patient has been receiving

ongoing therapy under a physical therapy plan of care and the physical therapist begins

the establishment of the maintenance program prior to the patient’s anticipated discharge

date.

EXAMPLE: A patient with Parkinson’s disease is nearing the end of a rehabilitative

physical therapy program and requires the services of a therapist during the last week(s)

of treatment to determine what type of exercises will contribute the most to maintain

function or to prevent or slow further deterioration of the patient’s present functional

level following cessation of treatment. In such situations, the establishment of a

maintenance program appropriate to the capacity and tolerance of the patient by the

qualified therapist, the instruction of the patient or family members in carrying out the

program, and such reassessments and/or reevaluations as may be required may constitute

covered therapy because of the need for the skills of a qualified therapist.

Example #2 is an outpatient scenario in which a patient who has not been receiving

ongoing therapy under a therapy plan of care needs a maintenance plan.

EXAMPLE: A patient with multiple sclerosis needs a maintenance program to slow or

prevent deterioration in communication ability caused by the medical condition. Therapy

services from a qualified speech-language pathologist may be covered to establish a

maintenance program even though the patient’s current medical condition does not yet

justify the need for individual skilled therapy sessions. Evaluation, establishment of the

program, and training the family or support personnel may require the skills of a therapist

and would be covered. NOTE: In this example, the skills of a therapist are not required

to actually carry out the maintenance program services and, as a result, are not covered.

Example #3 describes a scenario where the skilled services of a therapist would be

necessary to actually carry out the maintenance program services.

EXAMPLE: Where there is an unhealed, unstable fracture that requires regular

exercise to maintain function until the fracture heals, the skills of a therapist may

be needed to ensure that the fractured extremity is maintained in proper position

and alignment during range of motion exercises. In this case, since the skills of a

therapist may be required to safely carry out the maintenance program given this

particular patient’s special medical complications, therapy services would be

covered.

Example #4 describes another scenario where the skilled services of a therapist are needed

to actually carry out the maintenance program services.

EXAMPLE: A patient with a long history of Multiple Sclerosis has difficulties

transferring in and out of the wheelchair and maintaining range of motion (ROM)

of the lower extremities (LEs) due to increased spasticity muscle tone since the

most recent exacerbation episode of her Multiple Sclerosis. The beneficiary is

unable to walk but is independent with the use of her wheelchair. The beneficiary

needs to be able to safely transfer in and out of her wheelchair by herself or with

the assistance of a family member or other caregiver(s). After an individualized

assessment by the physical therapist, and given the patient’s overall medical and

physical condition, the skills of the physical therapist are required to instruct the

patient and/or caregivers in proper techniques of wheelchair transfers and LE

stretches due to the special medical complications from the progression of

Multiple Sclerosis. When the physical therapist determines that the patient can

carry out the transfers and stretching activities safely and effectively, either alone

or with the assistance of the caregivers, the skills of the physical therapist are no

longer necessary to furnish the maintenance therapy; and, the patient is discharged

from PT.

Example #5 describes a scenario where a patient on a maintenance program needs

intermittent review and possibly a new or revised maintenance program.

EXAMPLE: A patient who has a progressive degenerative disease is performing

the activities in a maintenance program established by a therapist with the

assistance of family members. The program needs to be re-evaluated to

determine whether assistive equipment is needed and to establish a new or revised

maintenance program to maintain function or to prevent or slow further

deterioration. Intermittent re-evaluation of the maintenance program would

generally be covered as this is a service that requires the skills of a therapist.

Should the therapist conducting the re-evaluation determine that the program

needs to be revised, these services would generally be covered.

Maintenance program services that do not meet the criteria of this section are not

reasonable or necessary and are not covered under §1862(a)(1)(A) of the Act.

The maintenance program provisions outlined in this section do not apply to the PT, OT,

or SLP services furnished in a comprehensive outpatient rehabilitation facility (CORF)

because the statute specifies that CORF services are rehabilitative.