For many, many years, there has been this long standing myth in the therapy world that in order for Medicare to reimburse for skilled therapy services, you must show patient improvement. Essentially, it has been thought that maintenance therapy is not reimbursable because as a therapist, you cannot show improvement for certain conditions, but rather you are focusing your treatment on maintaining a patient’s current level of function, which for a long time was seen as a no-no by insurance companies.
However, thanks to the Jimmo vs Sebelius case back in 2011 – 2013, this myth was disproven. According to The Center for Medicare Advocacy, “Jimmo v. Sebelius, was a nationwide class-action lawsuit brought against the Centers for Medicare & Medicaid Services (CMS) on behalf of individuals with chronic conditions who had been denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement.” In 2013, an agreement was made that Medicare coverage is solely determined by a patient’s need for skilled care, not on a patient’s potential for improvement. This was a significant win for not only patients with Medicare insurance coverage, but therapy providers as well.
Based on the outcome of this lawsuit, maintenance therapy is reimbursable by Medicare if the skilled therapy services are justified for the following disciplines: physical therapy, occupational therapy, and speech therapy. Another key thing to note is that the outcome of this settlement only applies to home health, skilled nursing facilities, outpatient therapy clinics, and inpatient rehabilitation hospitals/facilities.
Since maintenance therapy is reimbursable as long as it is justified, let’s discuss what exactly maintenance therapy is. Typically, skilled maintenance therapy is justifiable and covered in two specific circumstances:
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- If the skill and judgment of a physical/occupational/speech therapist is needed to design and educate a maintenance program to be carried out by non-skilled personnel (such as a personal trainer) or a caregiver. In this situation, Medicare will cover periodic re-evaluations of the patient to determine the efficacy of the plan of care and allow the therapist to make any necessary modifications, if applicable.
- The skills and judgment of the physical/occupational/speech therapist are required to provide skilled maintenance therapy due to the complexity of the services needed to maintain or prevent decline in a patient, or for safety reasons.
Maintenance therapy is often extremely beneficial for patients with neuromuscular disorders, such as ALS, Parkinson’s, Muscular Dystrophies, etc. which result in chronic impairments that impact their mobility and ability to function independently. In these particular cases, patients may likely benefit from ongoing therapy services to slow the decline of their condition, prevent exacerbations, manage pain and maintain their current level of functional independence.
While individuals with neuromuscular disorders will often benefit from maintenance therapy, a patient is not required to have a chronic and/or progressive disease in order for Medicare to cover maintenance therapy services. Medicare also does not require a patient to functionally decline before covering medically necessary skilled therapy. This means that if you are treating a patient with Medicare insurance, who is no longer making improvements but continues to require skilled therapy services, you can reassess the patient and develop a new plan of care which reflects the new maintenance therapy goals.
Below are some documentation tips you should consider to correctly document and show justification for skilled maintenance therapy:
- The patient’s medical condition and/or complexity of the therapeutic treatment requires the skills of a physical/occupational/speech therapist.
- Treatment cannot be safely and effectively carried out by the patient individually, or by a non-skilled person, such as the caregiver.
- The patient has the potential to functionally decline without skilled therapy services.
- The therapeutic treatment itself is reasonable and necessary, in relation to the patient’s condition, to maintain, prevent or slow down further functional decline.
- Frequency and duration of services are appropriate and match that patient’s goals.
- Make sure you are updating the status of that patient’s goals, especially as they are being achieved. Documentation should support and show the treatment’s effectiveness of achieving the maintenance therapy goals.
- Continue to utilize objective tests and measures for assessments and goals, such as BERG, 10 meter walk test, TUG, etc.
- Make sure your goals are appropriate for maintenance therapy. These goals should emphasize preventing unnecessary and avoidable complications, such as: deconditioning, muscle weakness, reducing fatigue, muscle contractures, promoting safety, and maintaining strength and/or flexibility.
Oftentimes, maintenance therapy is forgotten about, especially in outpatient clinics, resulting in patients being discharged and experiencing a functional decline, either rapidly or over time. Thanks to Jimmo v Sebelius, patients who would benefit from maintenance therapy now no longer have to worry about their therapy services being taken away or having to pay out-of-pocket for potentially life saving therapy. Remember to always consider whether or not the patient is appropriate for maintenance therapy before you discharge them so that there is no discontinuity in their plan of care! Whether you are providing documentation for progressive therapy services or maintenance therapy services, HelloNote is a therapy EMR software that will provide you with all of your documentation and billing needs.
Resources:
https://www.fshdsociety.org/wp-content/uploads/2019/08/Medicare-Maintenance-for-therapists.pdf
https://medicareadvocacy.org/jimmo-v-sebelius-the-improvement-standard-case-faqs/