Busting Medicare Myths (and Regulating Your Expectations), Episode 3
PDPM, Maintenance Therapy, and the Medicare Outpatient Therapy Threshold
By Kara Gainer, JD
The U.S. Centers for Medicare and Medicaid Services isn't known for easy-to-understand rules and regulations around Medicare. Unfortunately, that complexity can lead to misinformation, which can spread quickly.
In an effort to get everyone on the same page, I'm debunking some of the most prevalent Medicare myths I've been seeing lately on social media and in other venues. (Have a question that you would like addressed in a future installment? Send your ideas to email@example.com with "mythbusting" in the subject line.)
Myth: CMS changed the coverage requirements of OT, PT, and SLP services furnished in a skilled nursing facility.
Although the payment methodology for SNFs changed in October of last year, the criteria for skilled therapy coverage didn't: Patients must receive the skilled therapy services they need. Skilled therapy services are now reimbursed by Medicare under the Patient-Driven Payment Model, or PDPM. While PDPM does change the manner in which patients are classified into payment groups under the SNF prospective payment system, it does not change any of the coverage criteria or documentation requirements associated with skilled therapy service coverage. But most important, PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies made on their behalf.
CMS Fact Sheet on PDPM
APTA handout: What You Should Know About the Patient-Driven Payment Model
Myth: SNFs should require therapists and assistants to deliver the maximum amount of concurrent and group therapy (25%) for each discipline for each patient.
Although the PDPM includes a combined limit on group and concurrent therapy of 25%, you should deliver the mode(s) of therapy best attuned to individual patient needs and goals, and incorporate the provision of group and concurrent therapy into the patient’s plan of care. Group therapy documentation requirements remain the same: You must plan for a group in advance and document how group therapy will help each patient achieve their goals.
CMS Fact Sheet on PDPM (see "Concurrent and Group Therapy Limit")
APTA webpage: SNF Patient-Driven Payment Model
APTA handout: group vs. individual care decision tree
Myth: Medicare does not cover skilled maintenance therapy.
This one has persisted for a few years. There has been a longstanding myth that Medicare does not cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible. But it's just not true, and the Jimmo v. Sebelius final settlement sought to dispel this fallacy and clarify the rules to safeguard against unfair denials by Medicare contractors. The settlement agreement and the resulting revised manual provisions clarify that the Medicare program covers skilled therapy and skilled nursing services under the SNF, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline or deterioration (as long as all other coverage criteria are met). Specifically, the Jimmo settlement agreement required revisions in various CMS manuals to clearly state a "maintenance coverage standard" for both skilled nursing and therapy services. 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.
APTA webpage: Skilled Maintenance
CMS webpage: Jimmo Settlement
Myth: Maintenance therapy is not supported by PDGM.
Here's how CMS puts it in 2020 home health final rule: "It is the responsibility of the patient’s treating physician to determine if and what type of therapy (that is, maintenance or otherwise) the patient needs regardless of clinical grouping. CMS expects the ordering physician, in conjunction with the therapist, to develop and follow a plan of care for any home health patient, regardless of clinical group, as outlined in the skilled service requirements when therapy is deemed reasonable and necessary. Therefore, a home health period’s clinical group should not solely determine the type and extent of therapy needed for a particular patient." Also, beginning this year, PTAs can perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements.
CMS 2020 home health final rule
APTA handout: What You Should Know About the Patient-Driven Groupings Model for Home Health Services
CMS MLN Matters: Manual Updates Related to 2020 Home Health Payment Policy Changes
Myth: You must discharge patients from physical therapy when they reach the Medicare payment outpatient therapy threshold or targeted medical review threshold.
As long as skilled physical therapy continues to be medically necessary, you shouldn’t discharge Medicare patients when they reach the outpatient therapy threshold or the targeted medical review threshold. What used to be the Medicare therapy caps now are annual thresholds that you can exceed when you append claims with the KX modifier for medically necessary services. This change from the earlier "hard" therapy caps is the result of the Bipartisan Budget Act of 2018 (BBA of 2018), which provides for Medicare payment for outpatient therapy services including physical therapy, speech-language pathology, and occupational therapy services. If services exceed the annual threshold amounts, nclude the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. If you furnish medically necessary services over the targeted medical review threshold of $3,000, continue to affix the KX modifier and maintain the documentation to justify it. This medical review focuses on categories of providers deemed a higher risk for rejected claims.
Remember that the threshold is for physical therapy and speech-language services combined. I'll cover why that's the case in the next installment of this series.
APTA mythbusting blog series, episode 1
APTA webpage: Medicare Payment Thresholds for Outpatient Therapy Services
CMS Q&A sheet: Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage
CMS webpage: Therapy Services
Kara Gainer is APTA's director of regulatory affairs.