Maintenance Therapy

Medicare Coverage: Skilled Maintenance

In January 2014, the Centers for Medicare and Medicaid Services (CMS) issued revised portions of the Medicare Benefits Policy and Claims Processing manuals to clarify coverage of skilled therapy services in maintenance care. The revisions were mandated as a result of the Jimmo v. Sibelius settlement agreement reached in US District Court earlier that year. In the January transmittal, CMS reiterated its longstanding policy that skilled therapy services still may be covered even in situations where no improvement is expected, including when skilled services are needed to prevent deterioration. 

Assistants

Can a physical therapist or occupational therapist provide maintenance therapy in the home health setting? What about the assistant?

Yes, physical and occupational therapists who meet the Medicare definition for qualified personnel can provide skilled maintenance therapy. CMS has expressly excluded the physical therapist assistant (PTA) and occupational therapist assistant (OTA) from providing skilled maintenance services in the home health setting.

Coverage

If a patient is not improving or is not expected to return to his or her prior level of function from skilled nursing or therapy, does Medicare coverage for skilled nursing or skilled therapy services stop unless the patient deteriorates?

The Medicare program does not require a patient to decline before covering medically necessary skilled nursing or skilled therapy. For a patient who had been expected to improve, but is no longer improving, a determination as to whether skilled care is needed to maintain the patient’s current condition or prevent or slow further deterioration must be made, and if such skilled care is needed, a plan of care to reflect the new maintenance goals must be developed. If, however, a patient is no longer improving and there is no expectation of improvement and skilled care is not needed to maintain the patient’s current condition or to prevent or slow further deterioration, such skilled care services would not be covered.

When are skilled nursing or therapy services to maintain a patient’s current condition or prevent or slow further deterioration covered under the SNF, HH, and OPT benefits, assuming all other coverage criteria are met?

As long as all other coverage criteria are met, skilled nursing and therapy services that maintain the patient’s current condition or prevent or slow further deterioration are covered under the SNF, HH, and OPT benefits as long as an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist, registered nurse or, when provided by regulation, a licensed vocational or practical nurse, are necessary in order for the maintenance services to be safely and effectively provided.

Skilled therapy is necessary for the performance of a safe and effective maintenance program only when the needed therapy procedures are of such complexity that the skills of a qualified therapist are needed to perform the procedure, or the patient’s special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled. However, when the individualized assessment does not demonstrate such a need for skilled care, including when the performance of a maintenance program does not require the skills of a qualified therapist because it could be safely and effectively accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services are not covered under the SNF, HH, or OPT therapy benefits. To the extent provided by regulation, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are covered to the degree that the specialized knowledge and judgment of a qualified therapist are required.

General Documentation

What is the role of “documentation” in facilitating accurate coverage determinations for claims involving skilled maintenance care?

There is not any particular phraseology or verbal formulation as a prerequisite for coverage (although some areas of the Medicare Benefit Policy Manual do identify certain vague phrases like “patient tolerated treatment well,” “continue with POC,” and “patient remains stable” as being insufficiently explanatory to establish coverage). Rather, coverage determinations must consider the entirety of the clinical evidence in the file, and our enhanced guidance on documentation is intended to assist providers in their efforts to identify and include the kind of clinical information that can most effectively serve to support a finding that skilled care is needed and received— which, in turn, will help to ensure more accurate and appropriate claims adjudication.

Care must be taken to assure that documentation justifies the necessity of the skilled services provided. Justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that, in the case of maintenance therapy, the skills of a qualified therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.

Do you have to "label" a patient as restorative versus maintenance?

Yes, for patients/clients in need of skilled maintenance therapy, you should establish a maintenance program and in your documentation clearly show that the services are being provided for maintenance goals as opposed to restorative.

In maintenance therapy, you are not trying to improve function but just maintaining or decreasing the decline in status; so what type of long-term goals would one use?

You should be using functional measures to track the patient's status and use your clinical judgment and knowledge of the patient's various conditions to determine what reasonable expectations are. The patient may be able to maintain a certain level of function based on a functional measure, or with a disease that is progressive, you may have goals to decrease the decline of status with a slow decline of the results of the functional measures.

30 Day Re-assessment

Regarding the home health 60-day episode of care, what are the 13th, 19th, and 30th visit reassessment parameters with maintenance therapy?

The home health 30-day reassessments do not change for skilled maintenance therapy and should be done by each therapy discipline in the same manner for all skilled therapy. In your assessment, you should show why the services are skilled and why the patient still requires the skill of a therapist to carry them out to maintain function or prevent/slow decline.

Switching Care Plans

Can a patient change from an improvement course of care to a maintenance course of care, and vice versa?

Yes. The therapy plan of care should indicate the treatment goals based on an individualized assessment or evaluation of the patient. Skilled services would be covered where such skilled services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. The health care provider must continually evaluate the individual’s need for skilled care, as well as whether such care meets Medicare’s overall requirement for being reasonable and necessary to diagnose or treat the individual’s condition, and make such determinations on an ongoing basis, altering – on a prospective and not a retrospective basis – the treatment plan and goals when necessary.

If a patient's skilled restorative care is completed, and the therapist opts to keep the patient on a skilled maintenance level, must they document that the patient is being transitioned to a skilled maintenance program?

Yes, the transition from restorative therapy to maintenance therapy should be documented, as the goals for treatment will be different. The plan of care should be update to reflect the new treatment goals for the patient.

Insurance Coverage

Does the Jimmo Settlement Agreement apply to beneficiaries in Medicare Advantage plans?

Yes. Medicare Advantage plans must cover the same Part A and Part B benefits as original Medicare, and must also apply the standards for coverage of skilled care as clarified by the Jimmo Settlement Agreement.

Additional Coverage

Where can I find examples that demonstrate the coverage requirements for skilled services?

Chapters 7 (HH), 8 (SNF), and 15 (OPT) of the Medicare Benefit Policy Manual (100-02) contain many examples.