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The regulatory landscape surrounding physical therapy has seen several changes in recent months. The following information will help keep you current and better ensure that appropriate compliance policies are in place.

Jimmo v Sebelius

Prior to a court ruling in 2013, CMS routinely denied claims for skilled nursing and therapy services that sought to maintain a patient's condition and prevent further deterioration associated with chronic conditions such as muscular dystrophy and Parkinson disease. In Jimmo v Sebelius, a federal judge ordered CMS to stop applying the "improvement standard" to deny claims for skilled maintenance services. The court affirmed that skilled therapy is, in fact, medically necessary if it is intended to prevent a patient's deterioration and maintain his or her current condition. CMS was ordered to update its official policies and to educate Medicare contractors to prevent further improper denials.

Subsequently, however, plaintiffs returned to federal court to seek stronger enforcement of the Jimmo ruling. They noted that CMS has continued to deny claims for maintenance services and that some providers have elected not to offer such services for fear of claims denials. On February 2, the federal judge overseeing the settlement agreement ordered CMS to implement a Corrective Action Plan to provide additional education on the Jimmo ruling to Medicare contractors, patients, and providers.

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  1. 1. Jennings S. Targeting fraud and abuse in home health. PT in Motion. 2016;8(10):8-11.

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