Determining Medical Necessity of Outpatient Physical Therapy Services

Abstract

A patient referred for physical therapy may attend one or several therapy visits or may continue to re ceive ongoing therapy services several times weekly for several months. The question of the continued medical necessity of those services arises often.

Determination of medical necessity for continued therapy services requires knowledge of the natural history of diseases that may require therapy services, familiarity with the effectiveness of treatment alter natives for those diseases, and awareness of commu nity practice patterns. Accurate and complete docu mentation from the therapist or referring physician is required for the physician advisor or utilization review consultant to make an accurate determination of medical necessity. A structured format for provid ing this documentation is suggested.