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  • CMS Releases Summary of Manual Changes Based on Jimmo v Sibelius Agreement

    The US Center for Medicare and Medicaid Services' Medicare Learning Network (MLN) has released a summary of updates (.pdf) made to the Medicare Benefit Policy Manual as a result of the settlement agreement reached in Jimmo v Sebelius.

    The settlement agreement, reached in January 2013, reinforced Medicare's policy that when skilled services are required to maintain the patient’s current condition or to prevent or slow further deterioration, coverage cannot be denied because of the lack of potential for improvement.


    • They claim that this is merely a clarification; that nothing has changed. But, it sounds new to me. I thought we were never allowed to do “maintenance” care whether it was skilled or not, let alone treat to “prevent or slow further deterioration”. I thought one of the criteria to continue care was that progress must be demonstrated. What about the cap? Who makes the call on skilled need to slow deterioration? What if the public catches wind of this? Is maintenance care reimbursed at the same rate as rehabilitative/restorative care? They don’t make any comments on appropriate diagnoses for considering maintenance care. Joel

      Posted by Joel Dykstra -> =JRaEL on 1/24/2014 2:01 PM

    • They are not stipulating they will pay for maintenance therapy. They will cover the skilled services of developing a treatment plan to preserve best ability to function. It's a functional maintenance plan. Once established, the therapist must train care givers and discharge the pt.

      Posted by kate on 1/24/2014 5:40 PM

    • What if there are no caregivers capable of physically working with the patient . Sounds like a therapy for lifetime plan.

      Posted by Marie on 1/24/2014 8:01 PM

    • This clarification is quite important because it changes the paradigm under which PTs and others have practiced. Maintenance can be considered skilled and diagnosis is not relevant. What is relevant is that the PT documents that skilled care is needed to maintain (prevent) worsening function, or in other cases, slow the deterioration associated with degenerative processes. If you are preparing to discharge a patient and in your judgement know it's likely that you will have to return after a few weeks, discharge does not have to happen. Even it there are aides or others present who could do a home program, if you don't think he follow through will occur, you can continue to see this patient to prevent or slow functional decline. The implication is that we must now consider this possibility with all Medicare patients. think about it, if we begin in ernest to place those Medicare patients who need our skilled services long term, we may be able to reduce hospital admissions, falls, worsening of chronic conditions, etc….They are stipulating that payment is required for maintenance care, not just a plan. From the document: "that coverage of skilled nursing and skilled therapy services “…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.” Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition." This is good news for PT and for our patients and hopefully for our healthcare system.

      Posted by Sue Rinere O'Brien on 1/24/2014 10:23 PM

    • It's about time! So many families of children with progressive conditions have had to advocate and battle getting services that are medically necessary for quality of life. (Not to mention the therapists who stand behind them with letters and rational.) Let's hope these families can put their energies toward living and healing their hearts.

      Posted by Melissa Littlefield, PT, PCS on 1/25/2014 11:33 AM

    • Will be interesting to follow the comments on this thread. My interpretation is not potentially "PT for life" or a huge paradigm shift. Lacking family or caregivers to perform an established maintenance program does not create a need for covered skilled care-anymore than the lack of transportation to a clinic for care creates a "homebound patient" for the purposes of covered home health services. Ruling clarifies coverage does not turn on improvement standard, but on NEED for skilled care. Also, all the other Medicare regulations and limitations have not changed because of this. Caps is still in place, SNF requirements are the same.

      Posted by kateinwa on 1/25/2014 12:25 PM

    • Jimmo v Sibelius is a landmark case that needed to bring to the attention of policy makers the value of what we do for people with chronic conditions. It is our job as therapists to advocate for our patients who need us to. With most acute conditions, healing can be facilitated by physical therapy and this can be achieved within 3 months times. However, with many chronic conditions, often functional decline is prevented by physical therapy. And often, skill is required to be able to manage patients with chronic and sometimes complex medical conditions. Cheers to the patients and their families who stood up for what is right in this important case. Now many more people will be allowed to have the care they need to function at their maximal level.

      Posted by Caryn McAllister on 1/25/2014 6:55 PM

    • Typical Medicare. I'm not even sure they know what it means when they adopt new changes.

      Posted by Dr Earl E Folsom PT DPT CHT on 1/26/2014 1:14 PM

    • Has anyone out there been paid for skilled services are required to maintain the patient’s current condition or to prevent or slow further deterioration?

      Posted by glenn on 1/26/2014 2:06 PM

    • it is difficult enough to prove skilled care for improvement of function - G codes. imagine the quality of documentation required when a nurse for Medicare does a review. All therapies are still subject to the cap and ABN needs to be signed when exceeding cap.

      Posted by Don Walsh on 1/27/2014 8:18 AM

    • Totally different way of treating Medicare patients than I had been taught 24 years ago!! Despite CMS making these statements, it is important to remember that the MACs are the ones who are making the decisions on denials and they are private contractors. I have always been told that the MACs pay from CMS is largely dependent on the numbers of claims that they actually deny, so it will be very interesting how this all plays out in the future!

      Posted by Matthew Kellar -> =FP^<K on 1/27/2014 10:00 AM

    • We need to remember that we are talking about tax dollars. And we all have a role in being stewards of this limited resource; even the patients themselves. The public needs to be educated on appropriate utilization of these resources (PT services among other services).

      Posted by Joel on 1/30/2014 3:14 PM

    • I have several contracts with community based board and cares for severely involved CP/MR patients that are being discharged to these facilities due to the impending closure of the State Hospitals. These patients are an excellent example for the efficacy of a FMP. Multiple, slowly advancing therapy arthropathies, labile RIPs, dynamic swallowing pathologies relative to seating postures/seating platforms and PEG tube stability and tons of other considerations that all have ongoing needs for skilled intervention. I typically see them twice a month ongoing. Occasionally place them on active PT for several interventions, mostly for staff training or to position for current arising needs from posture/seating platform issues. I post their intermittent and goal G Codes as CM and CM respectively. The FMP documentation is basically a flow sheet of ranges, postures, skin issues, DME safety and fall abatement strategies. So far no problems over the past two years.

      Posted by Richard on 12/2/2014 3:20 PM

    • I want to thank all the posts here from the therapists who REALLY DO treat their patients like individuals and you are "appreciated " by this caregiver /spouse . Your reports are very detailed ( and with good reason ...the whole patient is your focus ) A patient with a knee replacement (TKR) is not the same as one with Controlled Recurring Angina , Osteo Arthritis & Parkinsons all non curable ...all have a deterioration factor that must be addressed . ....One is expected to get better in 3-6 months ....in an otherwise healthy individual . The other has many more issues involved ....Too many Pt's are churning out a "one size fits all" therapy ...Had several of those .....but the ones who look at the entire picture are the heroes & heorines of this post .....and this lawsuit was won for you ( and your patients ) . I THANK YOU FOR ALL OF THEM.

      Posted by Donna M on 6/21/2016 7:12 PM

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