Think back to 6th grade English class for a minute—remember those fun figures of speech? The metaphor…simile…hyperbole… onomatopoeia …alliteration. Do you remember the oxymoron?   You know the ones…jumbo shrimp…awful good…icy hot…friendly takeover.

Well, it was not too long ago that Medicare added a new oxymoron to the list….. Skilled Maintenance.

Skilled Maintenance therapy has been an active discussion in the skilled nursing facility (SNF) setting for a few years now. It all started in 2014 with the implementation of the Jimmo v. Sebelius ruling. 6 Years later, heads are still spinning in long term care…and it’s no surprise. It seems everyone has their own understanding of the rules. Some facilities took the concept of Skilled Maintenance Therapy and ran with it while others won’t touch it with a 10 foot pole! Therapists and administrators alike have been heard saying “Maintenance Therapy is now covered by Medicare.” Nooooo! Well, not exactly, anyway. There is more to it than that!

Let’s pick up our 10 foot pole and give Maintenance Therapy a poke or two and try to work out some of the confusion so long term care professionals have the information needed to make informed decisions about using Skilled Maintenance Therapy in your practice.

How We Got Here

In January 2014, the Medicare Benefit Policy Manual was revised as part of the Settlement Agreement in the Jimmo v. Sebelius case. Jimmo v. Sebelius was the lawsuit filed in 2011 by patient advocates arguing that Medicare coverage for therapy was being denied due to patient lack of improvement or progress. Part of the Settlement Agreement charged Medicare with clarifying in the Manual that an “improvement standard” did not exist and that coverage was not based on the patient’s ability to make progress. As part of the clarification, Transmittal 179  was issued containing all the revisions and clarifications in the Medicare Benefit Policy Manual for Skilled Nursing Facility (SNF) Part A & B, Home Health (HH) Part A & B and Outpatient Therapy (OPT) settings. Medicare made it clear that the Manual clarifications were just that, clarifications, and that no new coverage policies were in effect. Coverage was not being expanded upon. So if there were no changes in coverage, why did Jimmo v. Sebelius create such a fuss?

So What Happened?

We can all attest to knowing of at least one therapy case denied by Medicare due to “lack of medical necessity or progress made.” So basically, Medicare was called out on the carpet and scolded {rightly so} for denying therapy coverage for reasons that contradicted their own policy. Medicare’s punishment {The Settlement Agreement} was to publicly acknowledge {confess} that Medicare coverage is not based on progress, and to review with the nation, that they do, in fact, have a written policy that coverage exists for those who require the skills of a therapist to develop, implement and/or perform therapy to ‘maintain’ a patient status.

In the revision, Medicare used the terminology to describe this type of therapy to maintain a patient as “Skilled Maintenance.” Thus, a new type of therapy was born. {Not really} This type of therapy situation was always covered, just not advertised as policy, and as such, underutilized in the therapy community.

The Manual had always had the verbiage tucked away stating:

“To be considered skilled, therapy services must….be provided with the expectation, based on restoration potential, that the condition will improve materially in a reasonable and predictable period of time; OR the services must be necessary for the establishment of a safe and effective maintenance program; OR the services must require the skills of a therapist to perform the maintenance program.”

Now, as a result of the Settlement Agreement, Medicare was forced to shout it from the rooftops!

How It Used To Be

Confusion set in for most SNF therapists with the new term “Skilled Maintenance.” Why? For years and years, therapy services in long-term care were categorized in 1 of 2 ways – Restorative or Maintenance. 

Restorative was synonymous with “billable” and meant that that the intent of the skilled service was to restore lost function and the patient was expected to make reasonable progress in a predictable period of time. Restorative also covered therapy when progress was not really expected but therapy was necessary for goals other than progress. These types of situations all fell under the umbrella of “Restorative Therapy,” and there was no question that they were all skilled.

Maintenance, synonymous with “non-billable,” was a program that was initiated with residents who were at higher risk for declining without therapy, possibly due to a lack of attention from the unit staff in areas such as ambulation. (ie: “We put the resident on Maintenance because they never ‘get walked’ on the unit.”) Sound familiar? These non-skilled maintenance programs were established by the therapist and then carried out by the therapist assistant or therapy aide (in some states), even though the program could have been carried out by non-therapy staff (ie: nursing staff, family).

Those were the choices – Restorative OR Maintenance. Then… with the implementation of the Prospective Payment System (PPS) in 1996, the word Restorative became associated with the new term “Restorative Nursing.” This became a little confusing for both therapy and nursing because the term “Restorative” could no longer be used in isolation—was it Restorative Therapy or Restorative Nursing?  Coincidentally, when Restorative Nursing programs were introduced into long term care as a formal concept, one which was reimbursable under Medicare Part A, Maintenance Therapy began to fade away. Residents were transitioned from Maintenance Therapy to Restorative Nursing. {Consequently, this is also when the productivity shift began as therapy staff time was now focused towards PPS since Maintenance Therapy was not reimbursable.}

And Now?

Fast forward, the new term “Skilled Maintenance” entered the arena and seemed to be an apparent contradiction of terms. How could it be “Skilled Maintenance” if it was once either “Skilled or Maintenance?” Now therapists in long term care were left with the following choices for therapy programs:

  1. Skilled Rehabilitative
  2. Skilled Maintenance: To design a program for non-skilled personal to carry out or to design a program that required a therapist to carry out
  3. (Non-Skilled) Maintenance

So why can’t we just call “Skilled Maintenance” “Skilled Rehabilitative therapy with unexpected progress?” Why do we have to label it?

If it’s skilled, it’s skilled. Right? And if there is no improvement standard with Medicare, then why do we have to differentiate between Skilled Rehabilitative and Skilled Maintenance? Well, as clinicians, part of what we do is evaluate and set projected goals and outcomes. Based on our assessment, we typically know if a resident has potential to reach the goals or not, or if the resident requires a plan to maintain function that could be carried out by others vs. needing to be carried out by a therapist. It all comes down to our assessment and our documentation… or…. what we expect, progress or no progress. 

It all comes down to justifying our services and the choices we make for our residents by justifying Our Skill.

The Role of Assistants in Skilled Maintenance Therapy

When the Medicare Benefit Policy Manual was updated in 2014, very specific language about skilled maintenance therapy and the role of the assistant was added. The first update in December 2013 included restrictions in Chapter 8 (Part A) and Chapter 15 (Part B) prohibiting the assistant from furnishing skilled maintenance therapy programs to either population. In January of 2014, however, a Manual revision was released with the restrictions for Part A removed, leaving the restrictions for Part B in place. The regulations remain this way today. You can review the CMS document here.

Assistants are able to provide Skilled Maintenance Therapy to Medicare Part A residents in the SNF. However, Assistants are not able to provide these services for the resident under a Part B program {in the SNF, HH or OPT}.

Updated 2023: Medicare regulation changed to allow assistants to provide skilled maintenance therapy under Part B. This was a temporary rule during the PHE and was made a permanent rule prior to the end of the PHE.

New Therapy Assistant Billing Modifiers

Effective January 1, 2020, Part B providers began using new PTA and OTA Payment Modifiers, CQ and CO respectively, on billing claims to indicate if the treatment was provided in whole or in part by an Assistant. Though the modifiers are currently only used for data collection, effective 1/1/22 they will be used to identify service for a payment reduction of 15% . {This article will get you caught up on all the details.}

In Summary

The role of therapy in long-term care is to assist residents in reaching their highest level of function and then setting up a plan to assist residents in maintaining their highest level of function, either through skilled means or unskilled means.  Not all services provided by therapy are billable.

So here are the facts:

  1. Skilled Maintenance is a “real choice” in the SNF setting
  2. Medicare does not cover plain-old “Maintenance” therapy because maintenance it is not a skilled service
  3. Medicare only covers skilled care
    • Skilled therapy to restore or improve a condition
    • Skilled therapy to prevent or slow decline a condition
    • Skilled therapy to maintain a condition
  4. Diagnosis or prognosis is not a factor in deciding if a service is skilled….it is whether the skills of the therapist are needed
  5. Rules for Part A and Part B Skilled Maintenance differ
  6. PTA’s and OTA’s  could not provide Skilled Maintenance Therapy with Part B residents, only Part A. However, this rule was updated during the PHE and permanently reversed to allow assistants to provide skilled maintenance therapy in all settings for Part A and Part B.
  7. If a “maintenance program” can be carried out by a “non-skilled” person {resident, family member, nursing assistant, nurse, restorative aide…}, then the program is considered non-skilled and cannot be billed to Medicare.
  8. Documentation must support the need for Skilled Maintenance and clearly show a reviewer why the service could not be provided by non-skilled personnel

Need more information or detail regarding Skilled Maintenance Therapy?

Or use our JustAsk! Q&A forum to ask a question.

In Your Corner,

Dolores Montero, PT, DPT, RAC-CT, RAC-CTA

SNF Rehab and MDS Compliance Training

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