Based on recent experience, the Center for Medicare Advocacy provides this Practice Tip for providers and advocates for patients who need to change from an improvement mode to maintenance mode for nursing or therapy.
The Center is seeing decisions from Medicare Contractors requiring that providers obtain new orders when a patient’s goals change to maintenance skilled care from an expectation of improvement. It is not sufficient that goals are adjusted in mid-treatment without a new order.
Note the CMS guidance on the issue, quoted below.
The CMS Medicare Benefits Policy Manual (MBPM) states that a provider must receive new orders with new goals for either skilled nursing or skilled therapies when changing from restoration to maintenance:
MBPM Pub. 100-02 Ch. 8, Sec. 30.2.2.1
…However, if it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services. By the same token, the treatment goal itself cannot be modified retrospectively, e.g., when it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initial goal of treatment from restoration to maintenance. Instead, it would make such a change on a prospective basis only. (Emphasis added)
While this section of the MBPM is from the skilled nursing facility (SNF) Manual, Medicare coverage of skilled nursing services for home health care are incorporated by reference from the SNF Manual to the home health skilled nursing rules. In addition, the Home Health Manual has its own rules regarding therapies and establishing goals based on restoration or maintenance.
A Center attorney was recently able to ensure continued physical therapy services for a home health patient who had received a notice of non-coverage from his home health agency stating he had “plateaued.” The attorney provided information about Jimmo and asked the home health agency to obtain specific orders for maintenance physical therapy. When the orders were in place therapy continued and a Medicare denial, loss of services, and an appeal were avoided.