$1.3 million settlement marks second recent deal over SNF supervision of therapy providers

The Centers for Medicare & Medicaid Services has revised the Medicare Benefit Policy manual to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve, per the settlement in the high-profile Jimmo v. Sebelius case.

The Jimmo plaintiffs argued that Medicare was improperly denying claims based on an “improvement standard.” Under this standard, beneficiaries would only receive Medicare coverage for skilled care that would improve their conditions.

In January, a federal judge granted final approval of a settlement in the case. Under the deal, CMS agreed to update the Medicare manual and take other steps to ensure that claims are not denied under the “improvement standard,” which the agency emphasizes never was a sanctioned policy. The manual revisions are intended to accomplish this goal.

For example, section 20.1.2-Determination of Coverage now states, “Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care.”

Skilled care may be needed to maintain a current condition or prevent or slow a patient’s deterioration, the manual now explains.

The revisions also enhance guidance on appropriate documentation for claims involving skilled care. Providers must substantiate that skilled care rather than non-skilled care was needed, in order to be reimbursed for so-called “maintenance therapy,” according to an explanatory CMS Medicare Learning Network memo. Appropriate documentation is not “in and of itself” part of the definition of skilled care, but is the means by which contractors can determine whether skilled care is needed in a particular case, CMS noted. This is why the revisions include more specific guidance on this aspect of documentation. 

The manual revisions include specific examples of documenting skilled care. For instance, if a patient in a plaster cast has a circulatory condition that demands skilled care, the documentation should indicate the severity of the circulatory condition. Vague language such as “caregiver instructed in medication management” would not adequately support the need for skilled care, the manual notes.

Click here to access the revisions, released Friday.