The Jimmo Settlement Agreement in January 2013 states that qualification for Medicare coverage depends on the beneficiary’s or patient’s need for skilled care, either nursing or therapy (PT, OT, and SLP) services, and NOT on their potential for improvement. This agreement made the Centers for Medicare and Medicaid Services (CMS) update and clarify the Medicare Benefit Policy Manual (MBPM) Chapter 1 – Inpatient Rehabilitation Facility (IRF), Chapter 7 – Home Health, Chapter 8 – Coverage of Extended Care Services, and Chapter 15 – Covered Medical and Other Health Services. LW Consulting, Inc. (LWCI) has noted an increase in review by the Medicare Administrative Contractors (MACs) focusing on documentation to support the need for skilled services.

The revisions aimed to emphasize the Maintenance Coverage Standard under Medicare, which states that “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.” Coverage does NOT depend on the patient’s restorative potential but on whether the therapy intervention is required with reasonable and necessary services. This program focuses on either sustaining the patient’s current condition or preventing further decline, provided skilled therapy remains necessary for carrying out the plan of care.

CMS made a clear distinction between Restorative (or Rehabilitative) therapy and Maintenance therapy. It is important to understand that medical necessity is essential for all services covered under Medicare, and the required documentation elements for both Restorative and Maintenance therapy remain the same; however, the therapist’s documentation should state the purpose of skilled therapy is either Restorative therapy or Maintenance. What sets these apart is the purpose: Restorative therapy is for functional progress, while Maintenance therapy is to maintain a patient’s current condition or to retard further deterioration of the patient’s condition. Note that therapy may transition between the two based on the patient’s evolving needs, necessitating appropriate documentation and physician orders. Once the purpose of the therapy changes, there has to be a signed physician order that specifies therapy for maintenance or restoration, a new initial evaluation, and a plan of care.

Maintenance therapy is a reimbursable service as long as it is justified. Physical Therapist Assistants (PTAs) and Certified Occupational Therapy Assistants (COTAs) within their discipline’s State Licensure Laws – Scope of Practice and under the supervision of the Physical Therapists (PTs) or Occupational Therapists (OTs) are allowed to perform both Restorative and Maintenance therapy services. The change to allow PTAs to provide skilled maintenance came with the 2021 Physician Fee Schedule Final Rule, in which CMS permanently permitted physical therapists to delegate skilled maintenance therapy services to a PTA for outpatient services under Medicare Part B.

The medical diagnosis alone does not determine the appropriateness of skilled care, although patients with chronic or complex illnesses often can benefit from Maintenance therapy. The documentation should support the medical necessity of the services:

  • Demonstrating the unique skills and judgment of the therapist to establish and provide the Maintenance therapy program.
  • The high complexity of the services needed to maintain or prevent the patient’s decline or for safety concerns; OR To establish the Maintenance therapy program in order to educate and train non-skilled individuals or caregivers to carry out the program, which includes periodic reevaluations of the patient by therapist, follow-up on instructions and training, and determining the effectiveness or modification needs of the treatments carried out by non-skilled individuals or caregivers.
  • Utilization of patient-specific objective tests and measures for assessment and goals – e.g., Timed up and go (TUG), 10-meter walk, Barthel, BERG.
  • The appropriateness of the Maintenance therapy frequency and duration to support the goals, commonly, less frequent visits compared to Restorative therapy.
  • The documentation should be reviewed regularly to ensure that the therapy is still effective in achieving these goals. The effectiveness of Maintenance therapy must be documented:
    • If the goal is to maintain the patient’s current status – the documentation must clearly demonstrate the effectiveness of therapy in achieving this goal; OR
    • If the goal is to slow down the natural progression of the patient’s condition – the documentation should support that the therapy has successfully slowed down the deterioration of the patient’s status. It should be evident from the documentation that the natural progression of the patient’s condition has slowed down due to the maintenance therapy. The documentation should be reviewed regularly to ensure that the therapy is still effective in achieving these goals.

Let us discuss this scenario: A 69 year-old-male is admitted to the SNF following hospitalization for a fracture to the left femoral shaft sustained from a fall. He underwent an open reduction internal fixation (ORIF) and is non-weight bearing (NWB) on the left lower extremity for 3 weeks. His medical history includes a recent Parkinson’s disease (PD) diagnosis, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (DM). He was a professor at a university and was independent in all activities of daily living (ADLs), instrumental activities of daily living (IADLs), and active with several community and church organizations prior to the fall. His hospital course was complicated by unstable blood glucose levels, the need for continuous oxygen, the onset of angina, and the exacerbation of his PD symptoms (tremors, bradykinesia, neck and trunk rigidity). Moderate to maximum assistance is required for supine<>sit and bed<>wheelchair transfers. He is non-ambulatory.

After completing 6 weeks of Restorative therapy in the SNF, this patient moved to an independent living facility. Since moving to this new environment, the patient has been functioning at the level achieved while in the SNF and compliant with the home exercise program (HEP). However, due to his Parkinson’s disease, there are days wherein he struggles with sit-to-stand transfers but completes the task independently; he has difficulty when making turns while ambulating, which makes him feel unsteady. He does not want further deterioration of his mobility skills. On evaluation, his Gait Speed was 1.95 feet per second {<1.8 feet per second = risk for falls} and Timed Up and Go (TUG) was 13 seconds {≥13.5 seconds predictive of falls}. There are several daily activities offered at this senior community, and he intends to continue attending the activities that interest him.

The physician orders PT for Maintenance. In this case, complexities include his medical condition, objective tests that support safety concerns plus the history of falls (both the Gait Speed and TUG tests are indicative of fall risks), activity limitations that could impact his social and psychological well-being, new environment, the patient’s willingness to participate in therapy and his goal of not functionally deteriorating. Establishing goals such as HEP modification with independent patient carryover and maintaining the patient’s Gait Speed of ≥1.95 feet per second and TUG score of ≤13 seconds. Interventions to attain the goals may include therapeutic exercises for strengthening and flexibility to deter weakness and rigidity; therapeutic activities of transfer training focusing on techniques, hand placements, identifying appropriate chairs to sit on (examples: chairs with armrests versus chairs without armrests or firm chairs versus soft chairs); gait training with emphasis on step length and height, base of support and heel-to-toe pattern; and teaching of modified HEP. The subsequent documentation, on a per treatment basis, must show the expertise of the therapist by demonstrating the unique therapy skills through the implementation of the treatment;

  • describing the patient’s feedback and performance;
  • showing the teaching/education given to the patient; and
  • reaffirming the clinical decision on why the treatment is appropriate or being modified to suit the needs of the patient.

A periodic reassessment to make appropriate goal changes is recommended. Documentation should identify the effectiveness of the plan of care based on the patient’s response to the interventions rendered using the therapist’s knowledge and judgment.

Unlike Restorative therapy, wherein the patient’s functional progress substantiates the skilled therapy intervention, Maintenance therapy features the knowledge, clinical judgment, and specialized and distinct skills of the therapist to effectively address the complex needs of the patient plus safely implement the appropriate treatment. Even when therapy is for Restoration or Maintenance, the medical necessity must be supported through documentation that paints the picture of why, what, and how.

LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!