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:

Defensible Documentation Toolkit - Regular BannerDefensible Documentation Toolkit - Small Banner

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!

  • Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks Image

    articleJul 9, 2015 | 5 min. read

    Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks

    Hello, readers. Over the past several weeks, I’ve enjoyed answering a number of your questions regarding billing for PT services, so I’m excited to address the topic right here on the WebPT Blog. On June 19, 2015, the Office of the Inspector General (OIG) released a report involving an outpatient private practice physical therapy provider. In case you weren’t aware, the OIG—which is part of the US Department of Health and Human Services (HHS)—is basically the CMS …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • What’s Your ICD-10 IQ? [Edit] Image

    articleAug 10, 2015 | 1 min. read

    What’s Your ICD-10 IQ? [Edit]

    For months, we’ve gone on and on about ICD-10 testing: testing your coding processes, testing your software, and testing with your payers. Now, with under two months to go before the transition date, it’s time to test one more very important factor: yourself. After all, no matter how sophisticated your systems and software are, critical thinking—and more importantly, clinical judgment—will make or break your ICD-10 success.   Think you’re an ICD-10 Einstein? Take our quiz to prove …

  • Why Medicare-Enrolled PTs Can't Always Provide Treatment on a Cash-Pay Basis Image

    articleOct 27, 2016 | 3 min. read

    Why Medicare-Enrolled PTs Can't Always Provide Treatment on a Cash-Pay Basis

    Even if you feel comfortable with all things Medicare, chances are there’s a new rule in the works ( oh, looky here ) that could trip you up. Yes, the rules are always changing—and even the ones that have been in place for a while could get you stuck in a pickle (mmm, pickles). That’s especially true with the rules around providing treatment on a cash-pay basis , because your restrictions and obligations vary based on your …

  • What to Look for in a PT Biller Image

    articleJul 28, 2015 | 4 min. read

    What to Look for in a PT Biller

    In the words of American rock legend Tom Petty, “Good love is hard to find.” While I agree wholeheartedly with Mr. Petty’s wisdom, I think some rehab therapy practice owners might say good employees are even harder to find. And that certainly applies in the billing department. After all, your clinic’s billing operation is crucial to its financial well-being. One bad hire could mean the difference between your clinic achieving private practice rockstardom and hitting rock bottom. …

  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • 6 Biggest Factors Impacting Your PT Clinic’s Cash Flow Image

    articleJul 23, 2018 | 8 min. read

    6 Biggest Factors Impacting Your PT Clinic’s Cash Flow

    Most of us went into physical therapy so we could make a difference in our patients’ lives. PT can be extremely fulfilling and rewarding—and for many of us, owning a practice has been a lifelong dream. Once that dream becomes a reality, however, it can be a sobering experience. Bills need to be paid and bottom lines need to be met. It’s not always easy to bring in enough money to cover cancellations and billing snafus, not …

  • Should PTs, OTs, and SLPs use the New X Modifiers? Image

    articleNov 7, 2018 | 4 min. read

    Should PTs, OTs, and SLPs use the New X Modifiers?

    When it comes to Medicare, a lot can change in four years—whether it be the rise and fall of functional limitation reporting or answers to questions like, “Do outpatient rehab therapists have to report MIPS?” (You can get that answer here , by the way.) So, when CMS introduced the X modifiers back in 2015 and told PTs, OTs, and SLPs they wouldn't have to use them, anyone familiar with Medicare rules knew that advice was subject …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.