Rehabilitation in geriatrics is a challenging and extraordinary endeavor, but can be a vortex of possibilities, rumors and mythology. The mythology of skilled services in the SNF prove challenging and is often an overwhelming obstacle in the provision of services.
Myth 1: Speech therapy cannot be the only service to provide skilled services in the SNF.
According to Chapter 8 of the CMS Skilled Nursing Facility Manual, skilled services consist of “…the skills of qualified technical or professional health personnel such as … speech-language pathologists or audiologists;” As long as the services provided require the skills of a speech pathologist, even when that is the only discipline involved, the services are skilled.
Myth 2: A PT/OT/ST cannot evaluate a patient who was recently discharged from therapy without committing Medicare fraud/abuse.
As professionals who treat and care for the geriatric population, we know that a patient who was safe and independent for ADLs on Friday may have had significant changes by Monday that are not as apparent as hemiplegia or a fracture, but can still impact their balance and safety. Evaluate again.
Myth 3: An order for therapy can be satisfied with a screen.
A screen is defined as a “hands-off” review of the clinical record and discussion with the patient and caregivers. An evaluation consists of measurements, interviews, decision-making, goals-setting and intervention planning. The evaluation is a billable procedure; the screen is not.
Myth 4: If the patient is discontinued from skilled services and has a decline in function, the skilling service must resume within 30 days in order to be skilled.
According to Chapter 8, Section 184.108.40.206, a planned delay in skilled services outside of 30 days is allowed in cases where the delay is predictable and planned. An example is when services are discontinued because the patient is non-weight bearing, but will be allowed full weight bearing in six weeks. The skilling service can be resumed when the weight bearing increases.
And the most prevalent and pernicious myth that follows us in SNFs, is ingrained in our consciousness, and impedes our ability to serve our patients:
Myth 5: Progress is required in order to continue therapy and continue skilling.
Chapter 8, Section 30 of the Medicare SNF Manual states “Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care.”[emphasis mine]
The 2013 Jimmo vs Sebelius litigation affirmed Medicare reimbursement for maintenance therapy as long as the goals are maintenance-oriented, and the services provided can only be provided by a skilled therapist. By this definition, the comatose patient who will not make progress can still be skilled for therapy for positioning, spasticity inhibition, range of motion, wound prevention, and caregiver education.
Our only recourse in cases where mythology and rumor persist, is to turn to definitive documentation. The RAI Manual, the Medicare SNF Manual, and our state practice acts are valuable resources to verify and validate the best care for our residents and families.
Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.