Reason Code 5D200: Therapy Procedure Non-Skilled

Reason for Denial
Medicare coverage and payment are allowed for therapy services that are considered reasonable and necessary. In order to determine medical necessity for the therapy services, submitted documentation must support the services billed. It is the provider’s responsibility to submit complete documentation to substantiate that the services were medically necessary.

How to Avoid This Denial
Documentation that may be helpful in avoiding future denials and/or adjustments for these reasons may include, but are not limited to, the following:

Therapy-Specific Information and Hints

• Submit initial therapy evaluation
• Therapy units recorded and billed must be supported by the therapist’s documentation
• The initial therapy evaluation must clearly reflect the resident’s ability to retain instructions
• When therapy services are provided, there must be an expectation of improvement within a reasonable period of time
• Repetitious therapy exercises that could be performed by aides and/or nursing personnel are not considered skilled services
• Therapy is not required in a situation where a beneficiary suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the beneficiary gradually resumes normal activities
• If speech-language pathology (SLP) services are rendered for the treatment of dysphagia, submit all supporting documentation to establish the medical necessity of the billed services. This may include, but is not limited to, physician’s notes and test results; for example, a Modified Barium Swallow (MBS) and/or a Fiber-optic Endoscopic Examination of Swallowing (FEES).
• Specific documentation related to therapy services should be submitted for review. This includes, but is not limited to, the following:
  • Physician's orders for therapy services
  • All physician certifications and recertifications for therapy for the last two to three months prior to and including the billing period
  • Documentation to establish that the therapy services are of a complexity that requires the skills of a licensed therapist
  • All therapy treatment plans and treatment plan reviews since the start of care
  • Documentation, including physician documentation, to establish the medical necessity of the therapy services as it relates to the illness/injury of the beneficiary
  • Short-term and long-term goals (measurable)
  • Actual minutes/units of therapy rendered as documented on a log/grid for each HCPCS billed each day
  • Documentation of treatment modalities rendered
  • Progress notes for the last two to three months prior to and including the billing period
  • Level of function just prior to the spell of illness
  • Functional decline
  • Current level of function
  • Documentation must clearly establish that occupational therapy (OT) and physical therapy (PT) are not duplicating services

More Information

• CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220  (PDF)
• Responding to an Outpatient Therapy Additional Development Request