Defining “Medically Necessary” for Physical Therapy
We at MediGraph are in a unique position. As Physical therapy software providers, we
are presented with ongoing opportunities to interact with our subscribers and
receive feedback when updating our program.
However, another area of important feedback comes from potential
subscribers. We often receive calls from
therapists that are looking for documentation software because of a bad
experience with a RAC audit. These therapists
experience the hard way what we at MediGraph have been addressing for years; objective
standards are required to satisfy the ‘medically necessary’ component of
intervention. It does not matter if your
treatment was appropriate. It does not
matter if your skills enabled the patient to overcome a physical
impairment. It does not matter if you
increased the patient’s functional ability.
What matters is your ability to prove that what you provide is ‘medically
As previously stated for our subscribers, RAC audits
resemble IRS audits. Both of these
government sponsored hunting expeditions are poorly defined. When the unstated goal is recapturing revenue,
vagueness helps the RAC auditor to establish cause for obtaining a refund of
your fees, just as the ambiguity found in the thousands of pages of the IRS
code helps the IRS agent to extract their pound of flesh.
While there is case law to establish that physical
therapists’ judgments are based on their ability to evaluate the patient’s
condition (not based on the referring physician), this degree of autonomy does
not satisfy the medically necessary standard for CMS or for RACS. In a recent APTA podcast, the Stanford
University Center for Health Policy: Model contractual language for medical necessity
was mentioned as the model for determining what is medically necessary. Five
pillars were mentioned as the basis for satisfying the necessity standard: authority,
purpose, scope, evidence, and value. While
these five pillars should be the components of sound clinical decisions, it is
the last two categories, evidence and value, that the RAC auditors utilize to
define medically necessary and are the two areas that require the most
that intervention was necessary is easily established, yet the most susceptible
area where PTs fall short in their documentation to RACs. Value, as stated in the Stanford model, is defined
as the likelihood of the intervention to “Improve function, minimize loss of
function, or decrease risk of injury and disease.” Evidence and value are easily measured. Unfortunately, in today’s environment, if we do not consider proper documentation that satisfies evidence and
value of our treatment we leave
ourselves vulnerable to the RAC auditors’ axe.
The best way to provide evidence and value is with peer reviewed
functional tests and impairment measurements that eliminate subjectivity and
doubt. To accomplish this task,
MediGraph PT Software includes more than 300 tests and measurements with
references. Are you using these tools?
always, please call if I can assist you with this process.
for Health Policy: Model contractual language for medical
necessity. Developed at the workshop, Decreasing Variation
in Medical Necessity Decision
Making. 1999 Mar 11-13; Sacramento (CA). Available at