Eli's Rehab Report

With improvement standard’s dark cloud scattered, bask in the need based sun.

Medical necessity as well as appropriate documentation to support it is a critical part of ensuring that you get the reimbursement you deserve for maintenance therapy. To succeed, you’ll need to identify the residents with skilled therapy needs, set goals and provide treatment accordingly. Read on to learn how.

Background: As part of the Jimmo v. Sebelius settlement in early 2013, the Centers for Medicare & Medicaid Services (CMS) dramatically changed the so-called “improvement standard,” which Medicare contractors used in making claims determinations for skilled care coverage. 

CMS subsequently revised several parts of the Medicare Benefit Policy Manual, chiefly to emphasize that Medicare contractors may not apply an “improvement standard” as a basis for denying maintenance claims for which skilled care is required in the skilled nursing facility (SNF), home health and outpatient settings, according to a recent blog posting by quality liaison Cherie Rowell for Functional Pathways. 

How Medicare Coverage Has Changed

The Manual revisions provide that coverage for skilled care does not turn on the presence or absence of an individual patient’s potential for improvement, Rowell noted. Also, the Manual added the provision that coverage is based on the patient’s need for skilled care to improve or maintain his current condition or to prevent/slow further deterioration.

“As a result, CMS appears to refocus medical review efforts on the presence or absence of skilled care,” according to an analysis by Flagship Rehabilitation. To meet the skilled care criterion, your facility must assess the resident’s clinical conditions and show that they support the need for the specialized judgment, knowledge and skills of a registered nurse, licensed practical nurse (as applicable), or qualified therapist.

“In addition, to be considered a skilled service, the services provided must be a level of complexity such that they can only be safely and effectively performed by or under the supervision of such skilled staff,” Flagship said. But CMS also concedes that a service typically considered unskilled may be classified as a skilled service based on the individual resident’s special medical complications that necessitate providing the skills of a nurse or therapist.

Don’t Skimp on Documentation

“Per usual, the Medicare law provides for up to 100 days of coverage per benefit period,” said Kris Mastrangelo, president and CEO of Harmony Healthcare International, in a Dec. 23 company blog posting. “The Jimmo settlement confirms that Medicare coverage is available for skilled nursing and therapy that is needed to maintain a person’s condition or slow deterioration.”

Not so fast: Keep in mind that the Jimmo settlement did not change anything regarding the eligibility requirements, warns Marilyn Mines, RN, BC, RAC-CT, senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, IL. The settlement basically “clarified when skilled services may be needed to help the resident prevent or slow decline.”

Therefore, “the therapist does not have carte blanche to put a person on 100 days of therapy for maintenance,” Mines cautions. “Maintenance therapy by the licensed therapist is only going to happen in rare circumstances when the safety of the resident may be compromised unless a licensed person can perform the services. In many instances, the skilled therapist develops the maintenance program that is implemented by non-licensed personnel.”

Identify And Then Implement Compliantly

So now it’s up to your facility’s staff to ensure that you’re appropriately and actively identifying those residents with skilled therapy needs and providing treatment accordingly, Rowell noted. Not only must you ensure that the need for medical necessity is met through skilled service, but you must also provide documentation that supports that skill to ensure payment.

Indeed, CMS has stressed the need for appropriate documentation as a critical part of supporting the resident’s need for skilled services, Flagship stated. “By adding specific guidance on ‘best practices’ for documentation to several portions of the Manual, CMS appears to suggest that the absence or lack of such documentation may serve as the basis for a medical necessity denial.”

Include: To support maintenance therapy skilled services, your SNF must document in the resident’s medical record:

• The history and physical exam pertinent to the resident’s care (including the response or changes in behavior to previously administered skilled services;
• The skilled services provided;
• The resident’s response to the skilled services provided during the current visit;
• The plan for future care based on the rationale of prior results;
• A detailed rationale that explains the need for the skilled service in light of the resident’s overall medical condition and experiences;
• The complexity of the service to be performed; and
• Any other pertinent characteristics of the resident.

Heed These Tips for Maintenance Therapy Goal-Setting

In addition to documentation, goal-setting in the new culture of maintenance therapy is also crucial. “When considering how to approach setting goals for a patient receiving maintenance therapy delivered by a clinician, analyze the at-risk behavior or decline that would result from a lack of skilled intervention,” Mastrangelo advised.

Mastrangelo shared the following examples of goals to set for residents who require and would benefit from maintenance therapy services: 

• Physical Therapy:

• The patient will maintain ambulation to 250 feet without loss of balance or shortness of breath utilizing [device or type of strategy, i.e., step to] technique with physical therapy.
• The patient will identify potential fall hazards in path with potential loss of balance at 80-percent accuracy through daily skilled intervention.
• The patient will safely ambulate outside and manage barriers (doors, steps, obstacles) without loss of balance and minimal assistance from physical therapist.
• The patient will maintain the ability to perform [insert level of performance] sit to stand transfer with the rolling walker.
• The patient will maintain the ability to complete a complex standing task for five minutes to allow for grooming/hygiene tasks without demonstrating shortness of breath or excessive fatigue.
• The patient will maintain _____ degrees of lower extremity range of motion (ROM) s/p hip fracture without surgical repair to prevent irreversible fixed contracture at hip joint.

• Occupational Therapy:

• The patient will maintain a tolerance for ______ splint as applied by occupational therapy and periodic skin assessment for signs and symptoms of redness.
• The patient will maintain _____ degrees Active Assistive ROM (AAROM) UE to reduce risk of fixed bone contracture.
• The patient will tolerate feeding self with minimal assist, occasional verbal cues and hand-under-hand technique 100 percent of meals with occupational therapy to maintain current weight at ____ lbs.
• The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinson’s disease with significant intention tremors.

• Speech Therapy:

• The patient will tolerate a ground diet with no signs/symptoms of dysphagia or aspiration pneumonia with skilled speech therapy intervention.
• The patient will maintain use of safe swallowing strategies as instructed by speech therapy at each meal to prevent aspiration.
• The patient will perform oral motor exercises to maintain functional oral motor strength for speech and swallowing capabilities daily with speech therapy cuing and supervision.

Resources: To read a summary of the Jimmo case and settlement, visit www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf. For more information on the Jimmo-related changes to the Medicare Benefit Policy Manual, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8458.pdf.