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.
According to CMS’ 2020 home health final rule, physical therapist assistants and occupational therapy assistants can perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the PTA or OTA, 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.
What You Should Know
When considering a patient for a maintenance program, is it essential that they have a chronic, progressive diagnosis in order to see them under maintenance therapy?
No, it is not a requirement for maintenance therapy coverage that the patient have a certain 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. Skilled maintenance therapy is covered in cases in which needed therapeutic interventions require a high level of complexity.
What’s the difference between "maintenance" and "medically necessary"?
"Medical necessity" is required for all services covered under Medicare, as is the requirement that the services be skilled. The services can be rehabilitative, maintenance, or slowing of decline based on the physical therapist's ability to justify 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.
Can a patient with a chronic diagnosis such as Parkinson's disease be put straight onto maintenance program from findings from the initial evaluation?
Yes, the therapist can develop a maintenance program from the findings in an initial evaluation as long as the documentation justifies the need for skilled therapy to maintain function or prevent/slow deterioration. It is not necessary to establish rehabilitation/restorative therapy prior to the maintenance program.
In a SNF, can a PTA treat a patient for both restorative and skilled maintenance under Medicare Part B?
No, the PTA would not be able to treat the patient under Medicare Part B for skilled maintenance, but the PTA could treat the patient for rehabilitative treatment. The PTA could treat for both rehabilitative and maintenance therapy under Medicare Part A.
Can a physical therapist or occupational therapist provide maintenance therapy in the home health setting? What about the assistant?
Yes, physical and occupational therapists who meet the Medicare definition for qualified personnel can provide skilled maintenance therapy. Beginning in 2020, therapist assistants are allowed to perform maintenance therapy services under a maintenance program established by a qualified therapist under the home health benefit (Medicare Part A), if acting within the therapy scope of practice defined by state licensure laws. The therapist continues to be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days, in addition to supervising the services provided by the therapist assistant.
Can a PTA provide skilled maintenance therapy to a Medicare patient under Medicare Part B?
No. Pursuant to the Medicare Benefit Policy Manual, Chapter 15, Section 230.1(C), "The services of PTAs used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising physical therapist. PTAs may not provide evaluative or assessment services, make clinical judgments or decisions, develop, manage, or furnish skilled maintenance program services, or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws."