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When Doctors Don’t Define Medical Necessity

If you are a caregiver to an older loved one or a person with a disability who may be sent to physical or occupational therapy, you need to know about Medicare’s new rules on medical necessity.  For the past decade Medicare spending on outpatient therapy has been increasing at a rate of more than 10 percent a year, but the number of patients receiving therapy has been growing at less than three percent a year, so there have been about 1300 pages of changes.

       It really all comes down to the physical therapist.  Even if your physician writes a prescription for outpatient therapy, it is up to the physical therapist to determine if the therapy satisfies the Medicare requirements.  So that your loved one does not end up paying for service (because they can have therapy on demand), understand what the therapist looks for:

1.    Therapy must be aimed at addressing a functional deficit (such as the patient being restricted in some vital activity of daily living).

2.    The therapy has to be something that actually requires a therapist – that is, it could not be a self-improvement home effort.

3.    The therapy is not for maintaining good function; it has to be directed to – and make progress toward – improved function.

4.    Therapy must focus on improving something that makes a difference in the patient’s daily life; Medicare will pay for efforts aimed at self-care around their home, but not for training for a marathon.

5.    Therapy has to have a chance of succeeding; the therapist must determine that there is a strong likelihood of achieving goals that have been set forth.


       The guidelines are fairly clear and the therapist’s documentation must speak to these issues for the program to be covered.  And it is important to appreciate that Medicare’s governance will not object to any legitimate use of therapy; they just set the standards so that physical therapy is more than simply “going through the motions.”  You don’t have to read the whole 1300 pages of Medicare’s guidelines to appreciate how the revisions will affect therapy.  Check out what the American Physical Therapy Association says about making the guidelines work for the beneficiaries (click the link).


Charlotte Bishop is a Geriatric Care Manager and founder of Creative Case Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago.  Please email your questions to


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