Medicare does indeed cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible.
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. The 2013 Jimmo vs. Sebelius settlement sought to dispel this fallacy and provide clarifications to safeguard against unfair denials by Medicare contractors for skilled therapy services that aid in maintaining a patient's current condition or to prevent or slow decline.
Several nonfederal payers also have clarified their policies regarding the improvement standard and skilled maintenance coverage.
What You Should Know
When considering a patient for a maintenance program, it is not essential that they have a chronic, progressive diagnosis. Coverage is based on individualized assessment of the patient's condition and the need for skilled care to carry out a safe and effective maintenance program. In fact, the therapist can develop a maintenance program from the findings in an initial evaluation, such as for a patient with a chronic diagnosis of Parkinson disease. It is not necessary to establish rehabilitation or restorative therapy prior to the maintenance program, as long as the documentation justifies the need for skilled therapy to maintain function, or prevent or slow deterioration. Skilled maintenance therapy is covered in cases in which needed therapeutic interventions require a high level of complexity.
"Medical necessity" and "maintenance" do not mean the same thing. Medical necessity is required for all services covered under Medicare, as is the requirement that the services be skilled. Medically necessary services can be rehabilitative, maintenance, or slowing of decline, based on the physical therapist's ability to justify that they are reasonable and necessary and require the skills of the physical therapist. It is considered skilled to instruct caregivers and to periodically determine if they are carrying out an unskilled service.
PTs — and PTAs — are permitted to provide maintenance therapy services under Medicare Part A in home health and skilled nursing facility settings and across Part B settings. For Part A settings: Physical therapist assistants under the supervision of the PT are permitted to perform both rehabilitative and maintenance therapy services under a maintenance program established by a qualified therapist under the Medicare Part A home health or SNF benefit, if acting within the therapy scope of practice defined by state licensure laws. In addition to supervising the services provided by the PTA, the qualified therapist is still responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days. See more on Medicare payment for home health.
For Part B settings: PTs and, as of Jan. 1, 2021, PTAs, are permitted to provide skilled maintenance and rehabilitative treatment in Medicare Part B settings, including home health and SNFs. The change to allow PTAs to treat came with the 2021 Physician Fee Schedule Final Rule, in which CMS permanently permitted physical therapists to delegate maintenance therapy services to a PTA for outpatient services under Medicare Part B. (CMS will revise the Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230, to clarify that PTs no longer need to personally perform maintenance therapy services and to remove the prohibitions on PTAs from furnishing them.) PTs and PTAs still are expected to abide by existing rules that require the use of the CQ modifier when services are provided "in whole or in part" by the PTA.