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  1. Coffman, Anne PT, MS, GCS


Accurate documentation of gait training is essential for physical therapists and physical therapist assistants who provide services under Medicare. Gait refers to the manner of walking, whereas ambulation is the ability to walk. Recent government publications note the ways services do not meet Medicare guidelines and are thus not reimbursed as physical therapy. Skilled services may be provided when nonskilled services would be more appropriate. Skilled services may not be medically necessary. Staff purportedly providing skilled services may not have appropriate skill or experience. Maintenance therapy is not skilled therapy. Physical therapy services are considered reasonable and necessary when 4 requirements are met, namely, suitability for the particular diagnosis, need for skilled services, expectation that the condition will improve, and occurring in a reasonable time.


GAIT training or ambulation? One of the most frequent procedures in rehabilitation 1 is not always documented adequately. Physical therapists and physical therapist assistants providing services under Medicare need to document clearly that they are providing the skilled service of gait training. This article will explain the Medicare regulations regarding skilled therapy services and provide examples of strong and weak documentation for the provision of gait training.


What is the difference between gait training and ambulation? Guide to Physical Therapist Practice defines gait as "the manner in which a person walks, characterized by rhythm, cadence, step, stride and speed." 2(p81) The Guide, however, does not characterize ambulation. Taber's Cyclopedic Medical Dictionary states that gait is "the manner of walking: specific examples are ataxic, cerebellar, double step, drag-to, equine, festinating, gluteal, helicopod, hemiplegic, scissor, spastic, steppage, swing-through, swing-to, tabetic, three-point, twopoint, waddling." Ambulant is "able to walk, not confined to bed." 3 Both definitions indicate that gait refers to the manner of walking whereas ambulation simply indicates the ability to walk.


Gait training, therefore, requires assessment of the manner of walking and instruction, with or without exercises, to improve or correct the manner of walking. Documentation of this process would generally demonstrate that a skilled service is being provided to the Medicare beneficiary. In contrast, reporting that ambulation has occurred only indicates that the beneficiary has walked and does not, by itself, demonstrate the provision of skilled physical therapy services.


In recent years, the federal government has scrutinized therapy services. The Office of the Inspector General has published several reports regarding the provision of therapy services and compliance with Medicare regulations. Often, the findings concluded that the services do not meet Medicare guidelines and should not be reimbursed as physical therapy. The reports raised 3 key objections.


First, skilled services were often provided when nonskilled services would be more appropriate. "Medical Necessity of Physical and Occupational Therapy in Skilled Nursing Facilities" 4 objected to services that only aimed to increase strength or endurance or both; such services could have been provided by nursing staff.


Second, the same report noted that "therapists inflated 'billed time' by including time to transport or ambulate the patient to a therapy area. [horizontal ellipsis] While the therapist might give some safety and gait instruction during transport or ambulation, these are not considered skilled services, according to Medicare guidelines." "Physical and Occupational Therapy in Nursing Homes: Medical Necessity and Quality of Care" 5 addressed the same issue. Most skilled nursing facility (SNF) patients were appropriate candidates for physical therapy and occupational therapy and they benefited from therapy. Nevertheless, almost 13% of therapy was billed improperly, of which nearly three-fourths was not considered medically necessary.


A third finding was that many patients received therapy from staff with inappropriate skill or experience. A quarter of the improperly billed therapy was for this reason; half of the instances referred to a rehabilitation aide who provided care that was billed as skilled therapy. An aide who accompanies a patient who practices walking does not have the skills to assess nor intervene in the gait cycle. Only a physical therapist or physical therapist assistant can provide gait training; an aide is simply accompanying the patient, which is not a skilled service.


"Monitoring Part B Therapy for SNF Patients" 6 stated that almost three-fourths of Fiscal Intermediaries found medically unnecessary or excessive therapy claims, or both, during their general reviews. Their findings included the inappropriate billing of "maintenance" therapy as if it were skilled therapy. "Medical Necessity, Cost and Documentation under the $1500 Caps" 7 contained both favorable and unfavorable findings. It estimated that 87.7% of physical therapy claims were reasonable and necessary; however, 10% of therapy units were not supported by adequate documentation. The 10% equated to $8.7 million. A typical example was "one claim included one unit for 15 minutes of gait training on two consecutive days; however, the therapist stated in the progress notes that the patient refused treatment on both days."


A common thread in these reports is that unskilled services are sometimes billed as skilled service. While some investigations included on-site observation of service delivery, more often, decisions regarding medical necessity were based only on review of written documentation. The governmental reports clearly indicate that a substantial number of physical therapists do not document to meet the Medicare regulations for appropriate reimbursement. Although most physical therapists deliver skilled service, they do not always adequately document the level of skill provided. This author's experience as a consultant in many SNFs confirms that this was often the case.


Although Medicare regulations are written for specific settings, the concept of skilled therapy service is remarkably consistent across settings. Physical therapy services are considered reasonable and necessary when (1) the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition, (2) the services are of such a level of complexity and sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified physical therapist or under his/her supervision, (3) there is an expectation that the condition will improve significantly in a reasonable (and generally predictable) period of time[horizontal ellipsis] or the services are necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state, and (4) the amount, frequency, and duration of the services are reasonable. While the exact language differs very slightly, these regulations have been published in several documents. 8-10