Harmony Healthcare International (HHI) Blog

Maintenance Therapy: Top 10 Things to Know

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


TherapyServices.jpg

During Harmony Healthcare International’s (HHI) LTPAC Interdisciplinary Symposium, harmony16, guest speaker, Ali Bers, Attorney with Center for Medicare Advocacy shared her knowledge and passion for supporting ongoing skilled services to our elder population.  Here are the top ten things you should know about providing Maintenance therapy.

  1. Jimmo Clarifies Proper Standard: Therapy services are needed to maintain, prevent or slow deterioration so long as the beneficiary requires the skills for services to be safe and effective. What should be asked?
    1. Is a qualified nurse or therapist needed to provide or supervise a level of care?
    2. Regardless of whether the skills services rendered are to improve, maintain, or slow deterioration, is Maintenance care required?
    3. What are the skilled areas that require maintenance therapy? Ali Bers reminds providers to not base Skilled Maintenance therapy to the beneficiary’s medical diagnosis/ medical condition but on the need for skilled care. 
  1. “Rules of Thumb”:  Rules of thumb should NOT be used to deny services.
    1. DO NOT assume Medicare is unavailable based on:
      1. Rules of Thumb, Diagnosis, Wants or Needs 
  1. CMS Educational Campaign: CMS was required to issue revisions of CMS Manuals, provide educational material, explain the settlement and define Maintenance therapy services.
Jimmo and Improvement Standard
  1. Payer Sources: Applies to ALL payer sources coverage criteria required to be the same as those in original Medicare. 
  1. Understanding skilled care? To better support documentation of Maintenance therapy, assess the documentation and review if the following areas are supporting skilled coverage criteria. Review documentation for clinical observation and assessment, management of evaluation of care plan, teaching and training, skilled rehabilitation.   For Maintenance therapy, was emphasis placed on Management and Evaluation of Care plan, potential for complications, the relationship of services and their effect on each other?   Ali Bers emphasized that the documentation supporting the clinical justification for ongoing skilled services could include phrases such as “Reasonable probability for complication.” 
  1. Reasonable Probability:   Skilled care may be needed if potential complication of further acute episodes is likely. Individual circumstances may be necessary to prevent worsening symptoms for the medically unstable.  Patient education as an ongoing skilled services. 
  1. Documentation: Narratives: spell it out and show your work. Make sure your documentation highlights the response to treatment and changes and shows communication among members of care team. Establish a Maintenance goal or goals that prevent or slow decline. Consider a patient defined goal. Patients goals may be to remain walking, to slow down the loss of functioning and to remain independent for a little bit longer. Medicare coverage should be available if skilled nursing and therapy is warranted. 
  1. TWO Paths to Travel: Improvement versus Maintenance applies to all patients and is not based on clinical diagnosis. 
  1. End of Life Care: Comfort measure does not mean that there are no skilled care areas. Identify custodial services versus highly skilled services, including:
    1. Pain and symptoms, use of narcotics, anti- anxiety treatment, anticipating the effects and skilled end of life. 
  1. Where are we today? Four years later we are still facing barriers.
    1. CMS Initiatives/ Reforms: IMPACT Act of 2014, new factors in Five-Star quality rating, initiatives that prioritize improvement outcomes in function structural improvement
    2. Documentation barriers
    3. Inadequate research data on benefits of Maintenance therapy
    4. Audit concerns about acquisition of fraud, preventing people from receiving medical care
    5. Annual Medicare cap on certain therapies; reluctance to pursue exceptions
    6. Manual mandatory medical review for claims exceeding certain thresholds

In March of 2016 the Center for Medicare Advocacy went to court to enforce the ruling of the Jimmo settlement and they reiterated the inadequacy of the Educational Campaign that the Center for Medicare and Medicaid services were mandated to provide. In closing, Harmony Healthcare International (HHI) encourages providers to educate themselves on Maintenance therapy and stay on the lookout for further educational outreach from CMS.

Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores.  Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 
 

Topics: Maintenance Therapy, Jimmo

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