Let’s think back to our 6th grade English class for a minute—remember those fun figures of speech? The metaphor…simile…hyperbole… onomatopoeia …alliteration. Do you remember the oxymoron? “A figure of speech where contradictory terms appear side by side.” You know the ones…little giant….old news…larger half…deafening silence…jumbo shrimp.

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

Maintenance Therapy has been an active discussion in long term care for over a year now – starting in January 2014 with the implementation of the ruling of the Jimmo v. Sebelius case. And 15 months 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 have taken 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.No! Well, not exactly, anyway.

Today, we are going to 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 like you have the information needed to make informed decisions about using Skilled Maintenance Therapy in your practice.

Just to recap…

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 on January 14, 2014 containing all the revisions and clarifications in the Medicare Benefit Policy Manual, including those for skilled nursing residents under Medicare Part A and Part B. 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 as 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 were not even in their existing policy. Medicare’s punishment {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, Medicare had to shout it from the rooftops!

How It Used To Be

As an old school long term care therapist myself, here is my {unbiased opinion} on why confusion set in for most with the new term “Skilled Maintenance.” For years and years, therapy services in long term care were categorized in 1 of 2 ways – Restorative or Maintenance.

Restorative 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. Sometimes the resident did not make all the progress that was expected, or sometimes, progress was not really expected but the 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 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? Or maybe for a resident who loved therapy and could not cope with being discharged. Or maybe to transition a resident off a restorative therapy program. These non-skilled maintenance programs were established by the therapist and then carried out by the therapist assistant or therapy aide (in some states), and kept in place until the resident could be taken off Maintenance Therapy and maintained via daily routine nursing care.

So 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 the Medicare Part A, Maintenance Therapy began to fade away. Residents were transitioned from Maintenance Therapy to Restorative Nursing.

And Now?

So therapy choices went from being referred to first, as either Restorative or Maintenance, and then second, as either Skilled Rehabilitative or Maintenance. Then, 15 months ago, 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. When things don’t go as planned with a Skilled Rehabilitative program, we need to justify our actions to continue services based on a new plan of action, which may include Skilled Maintenance.

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

What is skill? Medicare Part A and Part B each have their own definition of what constitutes skilled therapy in the Manual. Similarities between A and B include that services must be reasonable and necessary, consistent with the severity of illness and of reasonable duration and quantity.  Services must be of a level of complexity and sophistication to require the judgement, knowledge and skills of a therapist.

Differences between Medicare Part A and Part B rest with the role of the Assistant (PTA, COTA) in Skilled Maintenance and the documentation to support the services.

Assistants (PTA and COTA) are able to provide Skilled Maintenance Therapy to Medicare Part A residents in LTC. However, Assistants are not able to provide Skilled Maintenance services for the resident under a Part B program.

This was an addition to Chapter 15 of the Manual in January 2014. With the initial Manual revisions put out in December 2013, the Manual included this restriction in Chapter 8 for Part A residents as well. This was then rescinded in January 2014 when the new revisions were released, leaving the restriction for Medicare Part B, which still stands today.

In Summary

The role of therapy in long term care today, as guided by the regulations in the State Operations Manual, 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.  A facility may also choose to offer unskilled maintenance therapy services to residents and these services can be carried out by licensed or non-licensed persons, though beyond the evaluation and set up of the program, these services are not covered by Medicare.

So here are the facts:

  1. Skilled Maintenance is a “real choice” in long term care therapy
  2. Medicare does not cover “Maintenance” therapy because maintenance it is not a skilled service
  3. Medicare only covers skill
    • 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 COTA’s  cannot provide Skilled Maintenance Therapy with a Part B resident, only Part A
  7. Documentation must support the need for Skilled Maintenance and clearly show a reviewer why the service could not be provided by non-skilled personnel

Skilled Maintenance Therapy can now be added to each therapist’s long term care toolbox. The decision to provide Skilled Maintenance Therapy can only be determined by the evaluating therapist. A long term care resident’s level of function fluctuates based on the nature of this fragile population and therefore, will likely cause residents to transition in and out of Skilled Restorative and Skilled Maintenance programs during their time in LTC. It is our responsibility to identify what residents need to attain and maintain their highest level of function, and then support our Skilled services through solid documentation. To justify Skilled Maintenance Therapy, solid documentation is reasonable…and necessary!

Need more information or detail regarding Skilled Maintenance Therapy?

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

In Your Corner,


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

Montero Therapy & MDS Resource Team

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