Jimmo guidance: Document whether therapy is for restoration or maintenance before providing care

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Jimmo guidance: Document whether therapy is for restoration or maintenance before providing care
Jimmo guidance: Document whether therapy is for restoration or maintenance before providing care

In seeking Medicare reimbursement, skilled nursing facilities should not claim that therapy was to maintain a patient's condition if documentation reflected only an improvement goal, according to officials with the Centers for Medicare & Medicaid Services.

CMS recently updated the Medicare manual in light of the high-profile settlement in Jimmo v. Sebelius. This clarified that Medicare covers so-called maintenance therapy for those who need skilled care but are not expected to recover prior functions or otherwise improve, and that contractors should not reject claims based on an “improvement standard.”

However, “it would be appropriate to consider the beneficiary's potential for improvement” in the case of services meant to restore function, according to information presented Thursday at a Medicare Learning Network call on Jimmo. Therefore, it is important for providers to document whether the goal of a particular therapy is restoration or maintenance.

The goal of therapy might change in the course of treatment, CMS officials acknowledged. In that case, documentation should reflect this change and describe an appropriate care plan to meet the new goal.

The key is that the documentation is prospective in nature. Problems will arise if a patient ends therapy, a provider determines that restorative goals were not met, and so the provider decides, “We're going to call it maintenance,” experts on the call said.

Only skilled maintenance therapy or care is covered by Medicare, so documentation must be detailed enough to show that the care meets this “skilled” definition, either because of its complexity or the complexity of the patient's conditions, officials said. However, the Jimmo settlement did not change any SNF regulations around the frequency or form of documentation. This means there is no requirement for SNF caregivers to write a daily note on the resident's response to therapy, as one provider on the call wondered.

Jimmo did not actually alter Medicare policy but only clarified existing policy, the CMS officials repeatedly emphasized. This means that the claims appeals process, therapy caps and 100-day utilization regulation are unchanged and apply to cases of maintenance therapy.

Officials on the call said they briefed contractors earlier this week on the implications of the settlement.

A transcript of the call will be available here.

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