Medicare does cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible if the services are medically necessary and meet the skilled care requirements.
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.
Note: Some commercial payers have adopted language and or revised policies that recognize the role of physical therapists in preventing decline or managing risk. Providers should check payer policy to see if there is a provision for skilled maintenance coverage.
What You Should Know
Skilled maintenance may include the design of and instruction in a maintenance program as well as the actual delivery of the maintenance program: When the knowledge, judgement, and skills of a qualified therapist are required to establish or design a maintenance program it meets Medicare coverage requirements. Additionally, delivery of the skilled maintenance program meets Medicare coverage requirements "when (a) the therapy procedures required to maintain the patient's current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient's special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures."i
The need for skilled maintenance is patient specific, not condition or diagnosis specific. 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, if the documentation justifies the need for skilled therapy to maintain function or prevent or slow deterioration. Ongoing skilled maintenance therapy is covered in cases in which needed therapeutic interventions require a high level of complexity.
Skilled maintenance must still meet the medical necessity requirements. 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 or maintenance, based on the physical therapist's ability to justify that they are reasonable and necessary and require the skills of the physical therapist. Establishing a maintenance program, instructing and training patients and/or caregivers in its implementation, and periodically assessing its effectiveness or need for modification meets the medical necessity requirement when the skills of a therapist are required.
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 skilled maintenance therapy services under a plan of care 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. See more on Medicare payment for home health.
For Part B settings: PTs and, as of Jan. 1, 2021, PTAs, are permitted to provide rehabilitative and skilled maintenance therapy under Medicare Part B, including when those services are provided in the home, assisted and independent living facilities and SNFs. 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. 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.
iMedicare Benefit Policy Manual, Chapter 15, Sections 220 and 230