There is a time and place for everything….

And now may be that time for skilled maintenance therapy in the SNF!

Skilled Maintenance therapy has been an active discussion for more than half a decade. It all started in 2014 with the implementation of the Jimmo v. Sebelius ruling, and heads are still spinning 7 years later…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 wouldn’t [and still 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 patients, including Glenda Jimmo, and multiple advocacy groups, against the Department of Health and Human Services, arguing that Medicare coverage for therapy was being denied due to patient lack of progress. They won the case and part of the Settlement Agreement charged Medicare with clarifying in the Medicare Manuals 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. The IRF and CORF settings were excluded. [If you have never viewed Transmittal 179, it’s worth a quick click, and will open your eyes to all the changes in red made in the HH, SNF and OPT settings, which are now part of the Medicare Manuals we use today.]

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 lack of progress.” Well, if you worked in the SNF, HH or OPT settings, this was NEVER a valid reason for denial of services. 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. Medicare was also required to clarify the wording in all the Manuals, educate their own contractors that review claims, and educate the public regarding what Medicare covers.

Medicare stomped their feet and updated the Manuals, but made it a point to say that “…these Manual clarifications were just that, clarifications, and that no new coverage policies were in effect. Coverage was not being expanded upon. Nothing was changing…” 

 So if there were no changes in coverage, why did Jimmo v. Sebelius create such a fuss?

The Manuals had always had this verbiage tucked away stating: [Seriously….this has always been in there….]

“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!

In the Manual revisions, Medicare added a new section entitled “Maintenance.” This may not seem like a big deal if you are well versed in Medicare language. But if you are not, and you took the word “Maintenance” at face value, not knowing how Medicare operates, you may have thought you hit the jackpot. Medicare will pay for Maintenance.

Not really.

If you know how Medicare operates, you know that they only pay for skilled care. So when they added a “Maintenance” section, it was obviously “skilled therapy to maintain” a status…. meaning all the rules for “skilled therapy” applied. 

So what Medicare was trying to convey when they clarified the wording in the Manuals was….”we will pay for skilled therapy if it is the only way to maintain a condition, or prevent/slow a decline in condition.” The “only way” meaning that the skills of a therapist (or assistant) were necessary, and that the service could not safely be provided by anyone other than a therapy professional, including a nurse, aide, family member or the patient themselves.

Medicare only pays for skilled care. Therefore, if they added a Maintenance section to their Manuals…..it has to be Skilled Maintenance. Thus, the new term “skilled maintenance” was born.

How It Used To Be

Confusion set in for most SNF therapists with the new term “Skilled Maintenance.” Why? For years and years, pre PPS,  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 1998, 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, clearly defined in the Manuals:

  1. Skilled Rehabilitative
  2. Skilled Maintenance: To design a program and pass it to non-skilled persons 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 no anticipated 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.

Progress is either anticipated or not. Skilled Maintenance is not a rehabilitative program where the resident failed to make the progress expected.

It is a pre-planned program of skilled care when progress is not intended. It is an episode of care in and of itself.

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.

Thankfully, the Final Rule for Part B that kicked in 1/1/21 stated that this restriction was lifted for Part B, now allowing assistants to provide skilled maintenance therapy in Medicare Part A and Part B settings. We may have COVID-19 to thank for this, as this was first a temporary rule added by Medicare at the start of the Public Health Emergency, then becoming permanent.

Can You Tie Skilled Maintenance in with Daily Practice in the SNF?

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. However, many of the “things” we do as therapists to make sure our long-term care residents attain and maintain their highest level of function, may very well be, and thus may qualify under skilled maintenance. Are you making recommendations to nursing for the “care plan” so that caregivers can provide care in a way that maintains highest level of function?  Are you providing residents with home exercises? Splints and wearing schedules? Routines using task segmentation? Swallowing strategies? Designing these maintenance programs for others to carry out utilizes your skill! And when a resident requires your skill to not only design the plan, but then also implement it, even if only for a short period of time while you are still evaluating the effectiveness before you pass it over to nursing staff, this is the heart of skilled maintenance!

So here are the facts for the SNF:

  1. Skilled Maintenance is a “real choice” in the SNF setting
  2. Medicare does not cover plain-old “Maintenance” therapy because maintenance 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 in terms of required documentation, etc.
  6. PTA’s and OTA’s  can provide Skilled Maintenance Therapy for Part A and Part B patients
  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

Refresh yourself with OBRA ’87 and the resulting Federal long-term care requirement to ensure your facility has a plan for each resident to attain and maintain his/her highest level of function. [F-675] What is your current plan? You may be able to integrate a solid skilled maintenance therapy program into your existing therapy services.

A win-win for sure!

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 Consulting

MonteroTherapyServices.com

Looking for more information on this topic? Check out our 3 contact hour course!

Course: Skilled Maintenance Therapy For SNF Therapy Professionals – The How-To & How-Not-To   

Includes tons of resources, including documentation templates for PT, OT and Speech Evaluations, Progress Reports, DC Summaries, and Daily Treatment Notes.

 

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