Skilled maintenance therapy has long been a service offering available for use in long-term care, yet this programming continues to be the source of confusion for many providers. ”Maintenance Therapy”, is often requested by patients and their representatives/families with the understanding that their loved one can continue receiving therapy to maintain function, or to prevent or slow decline. While this is true, there’s more to the story. Long term care professionals must understand the Medicare guidelines in order to make informed decisions about utilizing and billing Skilled Maintenance Therapy services.
The 2013 Jimmo v. Sebelius settlement clarified Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Specifically, the Jimmo Settlement Agreement required manual revisions to the Medicare Benefit Policy Manual to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits. This standard includes the following:
Skilled nursing services are covered where such skilled nursing 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. iii
Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. iii
Common Skilled Maintenance Therapy Myths:
- Patients must have a chronic condition for Skilled Maintenance Therapy to be covered.
False. Medicare coverage for skilled nursing or therapy services is not determined solely by a patient’s specific medical condition. Rather, an individualized assessment of the patient’s medical condition, as documented in the patient’s medical record, would be necessary in order to determine coverage.
- Skilled Maintenance Therapy is covered as long as the patient will benefit from ongoing services to maintain, or prevent functional decline.
False. Medical necessity is required for all services covered under Medicare, as is the requirement that the services be skilled. It’s important to keep in mind that skilled care may be necessary to improve, maintain or prevent decline in a patient’s current condition, but it’s not a presumption. Not every resident who needs ongoing maintenance therapy will meet skilled care requirements. Skilled maintenance therapy is covered when the needed therapeutic interventions constitute a high level of complexity. Coverage is based on an individualized assessment of the patient’s condition and the need for skilled care to carry out a safe and effective maintenance program. The documentation must support clearly what the clinician is doing that makes the service skilled.
- Skilled Maintenance Therapy must be delivered by the PT, OT, or SLP only (no PTAs or COTAs).
False. For Medicare Part A, PTAs and COTAs, under the supervision of the PT or OT are permitted to perform both rehabilitative and maintenance therapy services. For Medicare Part B, as of January 1, 2021, PTAs and COTAs, are permitted to provide skilled maintenance and rehabilitative treatment as well. The change to allow this came with the 2021 Physician Fee Schedule Final Rule.
- Patients cannot change from a maintenance course of care to a rehabilitation course of care.
False. The therapy plan of care should indicate the treatment goals based on an individualized assessment or evaluation of the patient. Services must be reasonable for the treatment of the patient’s condition when the services were ordered. Treatment goals cannot be modified retrospectively when restoration is no longer reasonably expected. (e.g., retroactively adjusting the initial goal to maintenance when it becomes apparent restoration goals are not reasonable). Instead make the goal change on a prospective basis only, defining if the services are rehabilitative or maintenance.
- Managed care plans do not allow Skilled Maintenance Therapy programs.
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.
The key word to consider when contemplating providing maintenance therapy services is “skilled.” Therapy services are likely considered skilled when the expertise of a therapist is used to develop or design an individualized maintenance program for a specific patient. But once the program is developed, the question is, can the program be carried out by non-skilled personnel (e.g., a nurse aide, family member, caregiver, facility staff, or as a home program by the patient themselves)? In some cases, the program could be delivered by non-skilled personnel with training from the licensed therapist. However, if the service can only be carried out by a qualified therapist due to the complexity of the patient and/or of the program, then the services would likely be considered billable as “skilled maintenance therapy.” Supporting this assertion requires extensive documentation from the therapist to indicate why the program cannot be carried out by anyone other than the licensed therapist, including charting that clearly demonstrates that the service provided is skilled, reasonable and necessary.
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- Transmittal 179: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf
- CMS Homepage for Jimmo vs Sebelius: https://www.cms.gov/Center/Special-Topic/Jimmo-Center
- CMS FAQ Document: https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs
- Chapter 15 Medicare Benefit Policy Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
- Physician Fee Schedule Final Rule CY2021 Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1