Medicare has debunked the myth of the “improvement standard and Jimmo v. Sebelius Settlement Agreement has guided CMS in policy updates to the home health, skilled nursing and outpatient therapy sections of the Medicare Benefits Policy Manual. Providers working in home health, skilled facilities and outpatient venues will now have to differentiate rehabilitative therapy v. maintenance therapy. It is an important distinction to make in that the ability to effectively implement a skilled maintenance therapy program turns on the ability of the clinician (nurse or therapist) to accurately assess the Medicare patient’s status in order to effectively design and document for a rehabilitative therapy v. maintenance therapy program.
Rehabilitative Therapy v. Maintenance Therapy – Definitions
Chapter 7 (home health), Chapter 8 (skilled nursing) and Chapter 15 (outpatient therapy) are now awash with updated examples and snippets of scenarios in which care may be considered skilled maintenance based upon the unique circumstance of the beneficiary and the documented need for skilled maintenance. In MM8458 CMS provides clarification on the difference:
In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally or with the assistance of non-therapists, including unskilled caregivers.
The use of a skilled professional alone does not indicate the need for maintenance care or therapy, but rather turns on the beneficiary’s need. Consider the patient that appears at your door hoping to have more therapy, or the staff member that heard that “maintenance is now covered”, or family members that insist on skilled maintenance for their loved one in the ALF to prevent a decline requiring a transition to a SNF.
CMS has made it clear, and has been incorporated into the Jimmo v. Sebelius Settlement Agreement , that “nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”
What are you anticipating for the patients that you typically see in your clinic? Are they candidates for rehabilitative therapy v. maintenance therapy? How will you decide? How will you apply the updated manual instructions? Is the difference between rehabilitative therapy v. maintenance therapy clear in your mind?