Documentation Essentials Part 05: Understanding Medical Necessity


This course will show how to make the documentation for therapy services support the need for medically reasonable and necessary therapy services. The student will learn the requirements set by Medicare B, as well as important tips on how to improve documentation to include medical necessity and skills of the therapist.

Course Goal

The student will be able to identify the key elements that should be present to support the medically necessity of therapy services for a Medicare B beneficiary.

Upon completion of this course, the learner will be able to:

  • Identify the six (6) essential components of documenting a medical necessity.
  • Identify three (3) strategies to include this documentation upon evaluation, in progress notes, and upon discharge to ensure payment.
  • Identify three (3) documentation pitfalls to avoid regarding writing a statement of medical necessity for therapy services.

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