by Director Mary Beck, OD, FCOVD

Medicare has recently updated their FAQ page regarding the Jimmo Settlement, approved by the court in January 24, 2013, which provides more clarification on the Maintenance Coverage Standards for therapy services including Outpatient Services (OPT).

Thanks to the Jimmo Settlement, the take home message is that Medicare cannot deny payment because the patient is no longer progressing if it is shown that therapy is important to maintain the patient’s current condition, prevent backslides, or slow down deterioration.

The core component related to therapy services and the Maintenance Coverage Standard that is key to remembering when documenting is the following:

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.

Precise documentation is key to demonstrating that maintenance therapy is medically necessary.

Care must be taken to assure that documentation justifies the necessity of the skilled services provided. Justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that:

  • In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
  • In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.

Read more about the Jimmo Settlement.