What does "necessary" mean to Medicare?

Skilled Necessity of Care

Defining "necessary" care can be a challenge. Part of that challenge stems from understanding what the word "necessary" means. To help understand that word better, let me introduce you to yet another word: "sufficient." The following illustration will help with understanding these words, and clarifying necessity.

I live in Ruther Glen, VA. To get from Ruther Glen (point A) to Richmond, VA (point B), which is about 30 miles away, I could drive my car- that would be a "sufficient" way to get there. I could also (if I was in good shape right now : ) ride my bicycle there- that would also be a "sufficient" way to get there. If I had a few days, I could walk there, which would be "sufficient." There are many options I have at my disposal to get from Ruther Glen to Richmond- all of them would be "sufficient" to complete the journey from point A to B.

If I wanted to take a trip to the moon (wouldn't that be cool!), it would be "necessary" for me to use a rocket- there are absolutely no other means at this time to get from Earth (point A) to the moon (point B). It is therefore not just sufficient, but necessary to use a rocket.

How does this relate to healthcare?

If a patient at SOC (point A) comes in to see me with a foot drop, and is having trouble with gait, I as a PT will be at least "sufficient" to get patient to the LTG of normalized gait (point B). However, it could be that the patient has a common peroneal nerve entrapment, and with the help of a surgeon, the nerve entrapment is relieved, and the patient receives improvement of his foot drop- that would also be a "sufficient" treatment plan to move the patient from SOC to LTG. Perhaps the patient could go to an orthotist, and get a custom orthotic, and have a "sufficient" result. There may be several sufficient options for this patient.

What Medicare and other insurers want to know is if YOU are the only rocket to the moon- if it is absolutely necessary that YOUR services are needed to get the patient from SOC to LTG. Your documentation will focus on the complex underlying impairments that it takes YOUR special scope of practice and skills to ID and treat. YOUR treatment will demonstrate key elements of complexity that can only be treated safely and/or effectively by YOU and no one else.

There are no bicycles to the moon. There should be no one else that can provide the patient a rocket ride from SOC to LTG outside of your discipline, and the art and science of proper documentation will support this.