This article will help to clear things up if you have ever been told, "You can't get more physical therapy for the year because you've reached the Medicare CAP." Or maybe you're concerned about using up your Medicare amount allocated for therapy, so you are avoiding further rehab this year.
Both cases are caused by misinformation and it is very important that you know the actual facts.
First of all, Medicare does NOT set a rigid limit on therapy services per year. In an attempt to track and contain costs, Medicare set up certain dollar amount markers (which were inappropriately referred to as "caps") as a way to track therapy expenditures. If a patient needs continued PT (physical therapy) past one of these dollar amount markers, the therapist simply attaches a modifier code when billing and must document clearly why the patient requires continued therapy.
Not very long ago, most therapists were under the impression that Medicare patients had to continue to improve to receive continued PT services. Unfortunately, for many older patients with chronic health conditions, improvement is not always realistic. Sometimes simply preventing further decline or deterioration is a huge success. Eventually, a patient with a chronic health condition sued Medicare because of this, and won.
The case was titled, Jimmo v. Sebelius, and many therapists are still just learning about it. In the settlement, they state that Medicare services are covered when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration. Although the original case dealt with a person with Parkinson's, the Settlement is not limited to any particular condition or disease. The settlement also applies to people who do not have chronic conditions, such as a stroke, or other acute event.
There are no time or visit limits set by Medicare. Medicare has therapy "caps", but there is an exception process to continue authorizing PT. This process is applicable to therapy without the expectation of improvement as well as if improvement is expected. "Part B payments can continue indefinitely, if coverage standards are met."
If a patient had been progressing, then plateaued, the patient does not need to decline in order to continue therapy services. If this occurs, the therapist must reassess the patient and develop a new plan around the maintenance goals.
This settlement also applied to patients with dementia.
Appropriate goals for maintenance therapy may include:
- Preventing unnecessary, avoidable complications from a chronic condition, such as deconditioning
- Muscle weakness from lack of mobility, and muscle contractures.
- Reducing fatigue
- Promoting safety
- Maintaining strength and flexibility
If a patient has a chronic neurological condition, appropriate goals may include:
- Maintaining joint flexibility
- Preventing contractures
- Reducing risk of skin breakdown
- Ensuring proper positioning
These rules apply to ACO insurance organizations and Medicare Advantage plans, too.
When would a patient ever be discharged from maintenance therapy? Although that's not very clear, if the patient does not require "Skilled" therapy services they could then be discharged. Skilled services are those that require specialized therapy knowledge and could not be provided by unskilled personnel.
“A patient's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.”
Therapists should record a baseline measurement and reassess with objective tests periodically to support effectiveness of therapy and support clinical decision making. These measures may not improve, but can be used to support maintenance goals.
Therapists should always document "responsiveness of the patient to the established course of care". Medicare calls this "progress". "Progress, or responsiveness to therapy, would be determined by the patient’s capacity to function at an optimal level, consistent with the stage or severity of the underlying progressive condition. " Basically, the therapist needs to show how they are affecting the patient's function with their intervention, even if that only means the patient isn't as bad as they might have been otherwise.
Just because a patient is on maintenance therapy does not mean their "rehab potential" is poor. Rehab potential is the patient's ability to respond to the therapist's intervention, even if the goals are maintenance-centered.
" Medicare patients are entitled to ongoing coverage, which may last years, as long as all coverage criteria are met."
"In addition, even though it may appear that the skills of a therapist are not ordinarily required to perform the specific procedures, skilled therapy is covered if the patient’s special medical complication requires the skills of a therapist to ensure proper healing and non-skilled individuals could not safely and effectively carry out the procedures.
The Jimmo Settlement specifically states that skilled therapy services are covered when the specialized judgment, knowledge, and skills of a qualified therapist are necessary for performance of a maintenance program. If the non-skilled personnel cannot ensure the maintenance of the patient’s condition, therapy is reasonable and necessary. "