Pain Assessment Subjective Reports Motivation & Compliance Functional Limitations (Golden Thread)

Environmental Barriers

Bed Mobility Transfers Assistance Level Functional Mobility Analysis (Skilled Intervention)

Assistive Device Assistance Level Weight-Bearing Status Affected Extremity Gait Characteristics Gait Analysis: Musculoskeletal (Skilled Intervention) Gait Analysis: Neurological (Skilled Intervention) Balance Analysis (Skilled Intervention) Stairs

Bed Exercises - Upper Extremity Sitting Exercises - Upper Extremity Support Level

Patient Education Provided Skilled Techniques Used

Select chips to build audit-defensible medical necessity justification for home-based physical therapy services.

Therapy Skill and Complexity

Documentation of skilled nature of intervention

Condition-Specific Justification

Diagnosis-specific medical necessity

Progress Toward Goals Safety & Risk Factors Plan of Care