My car is my baby. I get the oil changed and tires rotated regularly. And every few weeks, I take her through the wash and get her looking good as new. I won’t lie: I learned the importance of ongoing maintenance through much trial and error. Still, the cost of caring for my ride adds up, and it’d be nice if I didn’t always have to pay out of pocket for regular maintenance. And while caring for a car and caring for a patient aren’t exactly one and the same, there’s a pervasive myth in the PT world that Medicare patients must pay out of pocket for maintenance therapy. That, of course, is false: Medicare does cover medically necessary maintenance care. And yet, some providers remain hesitant to bill Medicare for maintenance therapy, operating under the false assumption that Medicare won’t reimburse them (or that the patient doesn’t qualify for reimbursement). With that in mind, here are three reasons to kick that assumption to the curb:
1. Medicare will pay for medically necessary maintenance care.
Medicare will pay for any services that meet its definition of medical necessity—and that includes maintenance services. Of course, nailing down what, exactly, Medicare considers medically necessary can be tricky. As we explain in this post, for Medicare to consider a covered service necessary, it must:
- “Be safe and effective;
- Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;
- Meet the medical needs of the patient; and
- Require a therapist’s skill.”
To many providers, that definition seems a bit, well, interpretive. This was actually the argument made by the plaintiffs in the Jimmo v. Sebelius case, which ultimately led to a settlement agreement that “clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility, Home Health, and Outpatient Therapy settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”
2. There’s no “improvement standard” for reimbursement.
Speaking of potential for improvement, another reason why some providers don’t bill Medicare for maintenance therapy is the so-called improvement standard (i.e., to qualify for reimbursement, the services must result in improvement of the patient’s function). According to CMS, though, Medicare statutes and regulations have never supported an improvement standard as a requirement for reimbursement. As mentioned above, coverage is not dependent on the beneficiary’s restoration potential, but rather, whether or not skilled care is necessary to meet the medical needs of the patient.
3. Medicare reimburses the same for maintenance therapy and rehabilitative therapy.
Finally, some providers believe that Medicare reimburses less for maintenance care than it does for rehabilitative care. But even if your patient has no potential for improvement—and the services you deliver are simply slowing down the patient’s health degradation—Medicare will still reimburse you at the same rate (provided those services required skilled care and are medically necessary).
Here are some additional considerations:
- There are no special CPT codes for maintenance therapy. When billing for maintenance care, you should bill the CPT code(s) that most accurately describe the skilled interventions you provided.
- While there’s no special code or modifier to indicate whether a therapy service is considered maintenance care or rehabilitative care, your documentation must clearly state when services are intended to maintain the patient’s function. If you switch a patient from restorative therapy to skilled maintenance therapy, you must also document that transition.
- For outpatient physical therapy, Medicare requires you to recertify the plan of care with the patient’s physician every 90 days—even if the patient is on a maintenance plan.
Maintaining your car can help it run better—longer. Maintaining your patients’ health can improve their quality of life for years to come. So, if your patient needs maintenance therapy, don’t hesitate to send the bill to Medicare. Have any other questions about Medicare and maintenance therapy? Drop them in the comment section below!