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[Blog Series] Making Sense of Medical Necessity for Therapy: Week 3

March 02, 2018
Documentation, Billing, & Coding By Armi Hernandez, Consultant

In week 3 of our blog series on making sense of medical necessity, we will discuss maintenance therapy as defined by the Jimmo Settlement Agreement (January 2013). Per the Jimmo Settlement Agreement, skilled maintenance services are Medicare covered services. The agreement required the Centers for Medicare & Medicaid Services (CMS) to make clarification updates in the Medicare Benefit Policy Manual (MBPM): Chapter 1 – Inpatient Rehabilitation Facility (IRF); Chapter 7 – Home Health; Chapter 8 – Coverage of Extended Care Services; and Chapter 15 – Covered Medical and Other Health Services.


The premise of the revisions was to reiterate the Maintenance Covered Standard for both skilled nursing and skilled therapy services provided under Medicare in a Skilled Nursing Facility (SNF), Home Health, and Outpatient Therapy.

What Constitutes Skilled Therapy

Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge and skills of a qualified therapist (skilled care) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.

For services performed in an Inpatient Rehabilitation Facility setting, the Jimmo Settlement Agreement clarifies that coverage should never be denied because a patient cannot be expected to achieve complete independence in the domain of self-care or because a patient cannot be expected to return to his or her prior level of functioning.”

Restoration and Maintenance Therapy

The skilled care eligibility, coverage criteria and evaluation elements for either restoration or maintenance therapy are the same. What differs is the justification for the plan of care based on the goals. It must highlight that only the distinctive skills of the therapist can maintain, prevent, or slow the further deterioration of the patient’s functional status and such treatments cannot be safely carried out by the patient or other non-skilled individuals. Remember that therapy for maintenance can switch to restoration and vice-versa depending on the needs of the patient. Once the purpose of the therapy changes, a signed physician order must specify therapy for maintenance or restoration, a new initial evaluation and plan of care.

Therapists have generally considered providing skilled therapy for restoration. This thought process can be modified when answers to therapists’ questions of “why me; why now” point to the appropriateness of the Maintenance Coverage Standard. Below, we apply the same scenario used in last week's series post:


A 69 year-old-male is admitted to the skilled nursing facility (SNF) following a fall with a fracture to the left femoral shaft.  He underwent an open reduction internal fixation and is non-weight bearing on the left lower extremity for 3 weeks.  His medical history includes a recent Parkinson disease (PD) diagnosis, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (DM). He is an anthropology professor at a university and was independent in all activities of daily living (ADL), instrumental activities of daily living (IADL), and active with several community and church organizations prior to the fall. His hospital course was complicated by unstable blood glucose levels, the need for continuous oxygen, the onset of angina, and exacerbation of his PD symptoms (tremors, bradykinesia, neck and trunk rigidity). Moderate to maximum assistance is required for bed mobility and transfers bed to wheelchair. He is non-ambulatory.

After completing 6 weeks of restoration therapy in the SNF, this patient moved to an independent living facility. Since moving to this new environment, the patient has been functioning at the level achieved while in the SNF and  compliant with the home exercise program (HEP). However, due to his Parkinson’s disease, there are days wherein he struggles with sit to stand transfers, but completes the task independently and has difficulty when making turns while ambulating which makes him feel unsteady. He does not want further deterioration of his mobility skills. On evaluation, his Gait Speed was 1.95 feet per second {<1.8 feet per second = risk for falls} and Timed Up and Go (TUG) was 13 seconds {≥13.5 seconds predictive of falls}. There are several daily activities offered at this senior community, and he intends to continue attending the activities that interests him.

In the above scenario, complexities include the patient's medical condition; objective tests that support safety concerns, plus the history of fall (both the Gait Speed and TUG tests are indicative of fall risks); activity limitations that could impact his social and psychological well-being; new environment; the patient’s willingness to participate in therapy; and his goal of not functionally deteriorating. It's recommended the therapist establish goals such as HEP modification with independent patient carry over, and maintain the patient’s  Gait Speed of ≥1.95 feet per second and TUG score of  ≤13 seconds.

Interventions to attain these goals may include

  • therapeutic exercises for strengthening and flexibility to deter weakness and rigidity; 
  • therapeutic activities of transfer training, focusing on techniques;
  • hand placements and identifying appropriate chairs to sit on (examples: chairs with armrests versus chairs without armrests or firm chairs versus soft chairs);
  • gait training with emphasis on step length and height, base of support and heel-to-toe pattern; and
  • teaching of modified HEP.

The subsequent documentation must show the expertise of the therapist by

  • demonstrating the unique therapy skills through the implementation of the treatment;
  • describing the patient’s feedback and performance;
  • showing the teaching/education given to the patient; and
  • reaffirming the clinical-decision on why the treatment is appropriate or being modified to suit the needs of the patient.

A periodic reassessment can be performed to make appropriate goal changes and identify the effectiveness of the plan of care based on the patient’s response to the interventions rendered, using the therapist’s knowledge and judgment.

Restoration vs. Maintenance Therapy

Unlike restoration therapy wherein the skilled therapy intervention is substantiated by the patient’s functional progress, maintenance therapy serves as “bragging rights” for the therapist to feature the knowledge, clinical judgment, specialized and distinct skills required to effectively address the needs of the patient and safely implement the appropriate treatment. Whether therapy is for restoration or maintenance, therapists must take credit for the difference their services make in the patient’s quality of life through documentation that paints the picture of why, what and how.


Does your medical record documentation support the need for skilled therapy? Receive one-on-one guidance through our Therapy Resource Partner program.
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