or adaptation to impairments in order to be covered.
• Maintenance therapy. Even if no improvement is expected, under the SNF, HH, and OPT coverage
standards, skilled therapy services are covered when an individualized assessment of the patient’s
condition demonstrates that skilled care is necessary for the performance of a safe and effective
maintenance program to maintain the patient’s current condition or prevent or slow further deterioration.
Skilled maintenance therapy may be covered when the particular patient’s special medical complications
or the complexity of the therapy procedures require skilled care.
Accordingly, these revisions to Pub. 100-02, Medicare Benefit Policy Manual clarify that a beneficiary’s lack of
restoration potential cannot serve as the basis for denying coverage in this context. Rather, such coverage
depends upon an individualized assessment of the beneficiary’s medical condition and the reasonableness and
necessity of the treatment, care, or services in question. Moreover, when the individualized assessment
demonstrates that skilled care is, in fact, needed in order to safely and effectively maintain the beneficiary at his
or her maximum practicable level of function, such care is covered (assuming all other applicable requirements
are met). Conversely, coverage in this context would not be available in a situation where the beneficiary’s
maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel.
The Medicare policy has never supported the imposition of an “Improvement Standard” rule-of-thumb in
determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus,
such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required,
along with the underlying reasonableness and necessity of the services themselves. The manual revisions now
being issued will serve to reflect and articulate this basic principle more clearly. Therefore, denial notices
should contain an accurate summary of the reason for denial, which should be based on the beneficiary’s need
for skilled care and not be based on lack of improvement for a beneficiary who requires skilled maintenance
nursing services or therapy services as part of a maintenance program in the SNF HH, or OPT settings.
In Pub. 100-02 (the Manual within which all revisions were made by CR8458), the revised chapter 15, section
220 specifically discusses Part B coverage under the OPT benefit. In that chapter, both rehabilitative and
maintenance therapy are addressed. Rehabilitative therapy includes services designed to address recovery or
improvement in function and, when possible, restoration to a previous level of health and well-being. A
“MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities
and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made
during therapy or to prevent or slow further deterioration due to a disease or illness.” No mention of improving
the patient’s condition is noted within the MP definition.
• Enhanced guidance on appropriate documentation. Portions of the revised manual provisions now
include additional material on the role of appropriate documentation in facilitating accurate coverage
determinations for claims involving skilled care. While the presence of appropriate documentation is
not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the
means by which a provider would be able to establish and a Medicare contractor would be able to
confirm that skilled care is, in fact, needed and received in a given case. Thus, even though the terms of
the Jimmo settlement do not include an explicit reference to documentation requirements as such, CMS
has nevertheless decided to use this opportunity to introduce additional guidance in this area, both
generally and as it relates to particular clinical scenarios. An example of this material appears in new
section 30.2.2.1 of the revised chapter 8, in the guidelines for SNF coverage under Part A.
CMS notes that this material on documentation does not serve to require the presence of any particular
phraseology or verbal formulation as a prerequisite for coverage (although it does identify certain vague phrases
like “patient tolerated treatment well,” “continue with POC,” and “patient remains stable” as being insufficiently
explanatory to establish coverage). Rather, as indicated previously, coverage determinations must consider the
entirety of the clinical evidence in the file, and our enhanced guidance on documentation is intended simply to