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Medical Necessity- Outcomes Likely the Missing Piece

Updated: Sep 25, 2019

The PRIMARY reason for Medicare to deny a claim is that the DOCUMENTATION does not show medical necessity.

What is medical necessity?

As defined by the Medicare Benefits Policy Manual, "The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function."

There we have it. Care that is considered medically necessary must show either

"recovery" or "improvement of function".

One of the absolute BEST, and easiest, ways to show an improvement of function is by utilizing outcome assessment questionnaires. Outcome assessment questionnaires are ideal because they address how the patient condition is affecting the performance of activities of daily living such as sitting, standing, driving, etc. This can be tracked over the course of treatment at each re-examination and will clearly outline the patient’s FUNCTIONAL progress (or lack of).

Remember that Outcomes work best when given at the following points of care:


  • Identifies and documents functional deficiencies

  • Establishes a baseline.

  • Utilize Outcomes at this stage to develop the SPECIFIC TREATMENT GOALS Medicare is looking for.

  • When setting goals for your plan of care, remember that the best ones are FUNCTIONAL, MEASURABLE, and SPECIFIC to that patient.


  • 2 WEEKS for Medicare


  • Re-examinations should be given every 4 weeks for Medicare.

  • Re-administering outcomes should be routine on re-exam visits. This is to measure and document functional progress.

  • This is also the time to re-assess FUNCTIONAL GOALS as part of your PLAN OF CARE. Document when goals you set initially have been accomplished and set new goals for the next phase of care.


  • This also includes flare-ups, new injuries, reactivation, etc.


  • Using Outcomes at this stage allows you to document where the patient rates functionally after a period of care. If they return later with an exacerbation or due to something such as an automobile crash, you will know exactly where they rated previously.



Both Medicare and commercial carriers are looking to see a

30% improvement between two consecutive Outcomes.

This is considered "significant improvement" and will help them determine medical necessity. If there is not sufficient improvement between consecutive Outcomes there should be documentation of changes to the treatment plan and/or complicating factors that account for the lack of progress by the patient.


The Care Plan

PER MEDICARE: A plan of care should be individualized for each patient and should include the following: • Recommended level of care (duration and frequency of visits) • Specific treatment goals (with documentation of progress or lack thereof within the clinical records) • Objective measures to evaluate treatment effectiveness (with qualitative and/or quantitative measures)


• How long you plan on treating the patient and how often • What you are working to accomplish • Criteria you will use to know when you have accomplished those things

The care plan should be thoroughly outlined at the INITIAL VISIT. Documentation of changes in the patient’s examination, status, progression, and care plan should be maintained in the records at each visit. This is to include goals that have been met over the course of care as well as any current or new treatment goals. ______________________________________________________________________________

For Example: If the patient filled out a Revised Oswestry Questionnaire and for #5 (sitting) they marked “Pain prevents me from sitting more than ten minutes.” One of your goals of treatment could be “to decrease pain in the low back so that the patient can sit for longer than 10 mins without pain”. You could use additional information combined with information from Outcomes Assessments to further elaborate.

Sample Initial Tx Plan: The patient will begin treatment at a frequency of 3 times per week for 4 weeks. Manual spinal manipulation, myofascial release, and therapeutic exercises will be utilized in office in addition to a home care exercise plan to help prevent re-occurrence. “Immediate treatment goals are to decrease pain in the low back from severe to moderate and to allow the patient to sit for longer than 10 minutes. Within the first 30 days of treatment, goals are to decrease low back pain from moderate to mild and enable the patient to sit for periods longer than 1 hour without increasing pain. Within 60 days, the goal is to reduce the patient’s pain level to “0” or “ 1” on the VAS scale, maintain the minimal pain level for 3 consecutive visits, and allow the patient sit for as long as desired without increasing pain. Re-evaluations will be performed every 30 days. Revised Oswestry Disability Questionnaire will be re-administered after the first 2 weeks of treatment and again at each re-evaluation. Pain will be measured on each visit using the VAS. Treatment goals and visit frequency will be re-assessed and modified per patient progress.


To schedule a complete Medicare training or for help with customizing your examination forms in Document Plus, please contact us at 800-642-0600.



Documentation of changes in the patient's examination, status, progression and care plan should be maintained in the records at each visit.

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