Therapeutic Exercise

Therapeutic exercises are the systematic and planned performance of body movements or exercises that aim to improve and restore physical function. The focus of therapeutic exercises is on regaining flexibility, strength and endurance related to specific physical problems. Therapeutic exercise requires direct contact with therapist used to develop strength, endurance, range of motion and flexibility. This may be accomplished with any of the following types of exercise:

• Active Movement
• Active-Assisted Movement
• Passive Movement
• Range of Motion
• Stretching
• Gross Movements
• Fine Movements

*1 unit = 15 mins

Typical flow of care

• Beneficiary reports complaints of a disabling condition to the physician
• Physician refers for therapy
• Therapist evaluates to identify impairments and appropriate treatments (therapeutic exercise) and develops the plan of care (POC) (if documentation does not support activity limitations and participation restrictions treatment is not warranted)
• Therapeutic exercises ordered should require the skilled care of a therapist

Medical necessity — four main requirements

• Presence of a disabling condition
• Individualized treatment
• Expectation that the beneficiary will benefit from therapy
• Requires skilled care

Presence of a disabling condition

• The impairment should be causing activity limitations and participation restrictions in the beneficiary’s daily life:
  • Examples: Difficulty walking, bending, dressing, bathing, engaging in family life, picking up grandkids, transferring a loved one, etc.
  • Pain is an appropriate condition if it is a disabling impairment for the beneficiary. If the beneficiary considers pain insignificant it is not disabling.
• Typically identified on the evaluation
• Per the LCD, include one of the following: weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance (pain is not listed, but it is acceptable as pain typically can cause several of the above conditions)

Individualized treatment

• Individualized exercises chosen by the therapist should address the specific impairments of the beneficiary (these treatments should relate to the specific impairment and goals for the beneficiary)
• Should include goals related to the activity limitations or participation restrictions identified
  • Per the LCDs, goals should address the following: patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation

Expectations the beneficiary will benefit from therapy

• Restorative: Goals should be to reverse decline, restore previous function (improve current condition)
• Maintenance: May be no documented decline, but instead a goal to prevent or slow further decline in functional status
• Should be a documented reasonable concern that the beneficiary will deteriorate without services
• Expected outcomes should be included in the POC
• Progress Notes should support the progress being made toward the expected outcomes

Required skilled care

• Each line of service billed for 97110 must meet skilled care criteria and performed by the therapist on the DOS for 97110 (if the service could be provided by someone without the skills of a therapist it is not skilled)
• Documentation should justify why the services provided are skilled:
  • Assessment of beneficiary (evaluation)
  • Development of the POC
  • Teaching the beneficiary new exercises
  • Monitoring the beneficiary when needed — special circumstances should be documented for each date of service such as medical monitoring (example: a cardiac condition that requires vitals be monitored during exercise, or a beneficiary who is not safe to perform exercises without supervision)
• Keywords in documentation to support use of skilled care:
  • Educate, education, corrected, instruct, instruction, trained, directed, reassessed, medical monitoring
• Frequency should be adjusted based on beneficiary’s needs:
  • Restorative — Typically may begin more frequent and then decrease
  • Maintenance — There should be a rate of decline expected or observed from one visit to the next:
    • If declining between visits it may be appropriate to increase frequency
    • If stable between visits it may be appropriate to decrease until a decline is noticed

Required documentation

• Evaluation: 
  • Should occur at the start of care (SOC) and be performed by the therapist
  • May be documented with the POC 

Evaluations should include:

• Impairment-based diagnosis, description of problems to be treated and impacted body part
• Conditions and complexities that may impact the patient’s treatment, such as previous function, date of onset and current function
• Use of tools with objective measurements to support that therapy is needed:
  • Patient Inquiry by Focus On Therapeutic Outcomes (FOTO)
  • Activity Measure — Post Acute Care (AM-PAC)
  • OPTIMAL by Cedaron through the American PT Association

If the record does not include one of the above tools, it should include one of the below:

• Functional assessment of individual items and summary scores, with any available comparison to prior assessment scores when applicable, from other available tools
• Clinical judgement or subjective impression that describes the current functional status of the condition being evaluated, when further information to supplement measurement tools is provided
• Determination that treatment is not needed, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with the expected time frame and a plan of care

Plan of care (POC)

• Created at SOC by the therapist 
• All services must be provided under a written POC
• May only be written by the Therapist or MD/NPP
  • Person developing must authenticate the document with signature, professional ID and date

The POC must include:

• The diagnosis services are being provided for
  • Type, amount, frequency and duration of services to be furnished
  • Type of therapy needed
  • Amount — number of times in a day the type of therapy will be provided
  • Frequency — number of times in a week
  • Duration — number of weeks or treatment sessions to be provided
• Goals that address the activity limitations and participation restriction affecting the beneficiary

Significant changes to the POC

• Must be made by the MD/NPP or the therapist
• If made by therapist must include written/verbal approval from MD/NPP to make the change
• Significant changes include long term goal changes, shifts in focus of care from strength to endurance or from restorative to maintenance
• All significant changes require the MD/NPP to resign the POC within 30 days of the changes
• Should also be documented in the progress notes

Certification

• Must occur within 30 days of the initial treatment
• If signed by verbal order, it must be signed within 14 days following the verbal order (verbal order must be submitted with POC)
• If not signed by the 60th day an explanation of delay must be submitted

Recertification

• Must be signed on or before the 90th day or have an explanation of delay
• Must address the need for continued services

Progress notes

• Should be submitted every 10 treatment days (not calendar days)
• Must be documented by the therapist or MD/NPP providing therapy service
• Should include assessments of progress or lack of towards goals, along with documentation that therapy continues to be reasonable and necessary
• Therapist — must have actively participated in any of the treatment sessions during the reporting period (if record doesn’t support this, a statement of “delayed active participation” explaining why and how the services remained skilled must be submitted)
• MD/NPP — must provide at least one treatment session during the reporting period

Treatment notes

• Should be submitted for every date of service (DOS) billed for 97110
• Should include list of services provided for DOS and time coded and total treatment minutes
• Should be signed by the person who provided services on that DOS

Resources

• CFR: § 410.59, 410.60, 410.61
• CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.5.2 — “incident to” regulations
• CMS IOM 100-02, 15, 220-230.1: Coverage of Outpatient Rehab Therapy Services
• LCD 34428: Outpatient PT
• LCD 34427: Outpatient OT
• CMS Presentation for Outpatient Therapy