Vol. 13 Issue 1
Medicare Guidelines for PT and Maintenance
Subacute and long-term care
As therapists working in subacute and long-term care facilities, we are often asked to make judgements regarding care that constitutes skilled physical therapy versus care that is restorative or maintenance in nature. Generally, health care practitioners in skilled nursing facilities define rehabilitative/ restorative care in three ways:
Skilled Therapy: Skilled rehabilitative care provided by physical and occupational therapists and speech-language pathologists to improve and restore function.
Restorative Care: Non-skilled rehabilitative care provided by restorative aides and restorative nurses to improve or maintain function.
Maintenance Care: Routine, repetitive activity necessary to maintain function usually provided by certified nursing assistants.
In contrast, Medicare guidelines provide two definitions. Physical therapy is referred to as both "skilled therapy" or "restorative therapy." These services are paid for by Medicare and are directed by a physical therapist.
Alternately, a "restorative nursing program" is equated to a "maintenance program" and is directed by nursing after nursing or therapy establishment of the program. This article will further distinguish the difference between skilled physical therapy and restorative or maintenance programs as defined by Medicare.
Skilled Physical Therapy
In order for physical therapy (also called "restorative therapy") to be covered under Medicare Part A or Part B, the following criteria must be met:
1. The services must be related to an active written treatment plan designed by the physician after any needed consultation with a qualified therapist. Under Medicare Part A, treatment may begin prior to return of the signed plan of treatment but billing may not occur prior to certification (by signature) of this treatment plan. A physician must recertify at intervals of at least every 30 days.
Under Part B, an oral clarification order is required prior to beginning treatment and recertification must include evidence in the clinical record that the patient has been seen by a physician at least every 30 days.
2. The services must be of a level of complexity and sophistication or the patient's condition must be of a nature that requires the judgment, knowledge and skills of a qualified physical therapist. This means that these services can be safely and effectively performed only by or under the supervision of a physical therapist.
3. The services must be provided with an expectation that the condition of the patient will improve in a reasonable and generally predictable period of time or for the establishment of a safe and effective maintenance program. Medicare reviewers are instructed to pay for service until there is no longer an expectation for improvement.
4. The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patient's condition. Medicare guidelines list skilled services provided under a physical therapist's scope of practice and non-covered services.
5. The services must be reasonable and necessary for the treatment of the patient's condition. Usually, documentation of complications and safety issues related to patient impairments and functional limitations provide evidence that service is reasonable and necessary. The amount, frequency and duration of services must also be reasonable and necessary for the patient's condition.
Restorative or Maintenance Programs
Medicare defines "restorative" or "maintenance" programs as repetitive services required to maintain function that do not involve complex and sophisticated physical therapy procedures and do not require the judgment and skill of a qualified therapist for safety and effectiveness.1
However, the judgement of a physical therapist may be needed to establish a maintenance program.
In the establishment of a maintenance program, the following services constitute skilled physical therapy:
• The initial evaluation of the patient's needs;
• The design of the program appropriate to the capacity and tolerance of the patient;
• The instruction of the patient or supportive personnel in carrying out the program;
• Re-evaluations as required.
Medicare cautions that the physical therapist should have already designed the required maintenance program and instructed the patient and supportive personnel in implementing the program before it is determined that no further restoration is possible (or that skilled physical therapy is no longer needed).
When the PT does not establish the maintenance program until after the skilled ("restorative") physical therapy program has been completed, no further physical therapy services are considered reasonable and necessary and are not covered. In other words, development of a maintenance program should be anticipated and accomplished concurrently with skilled intervention. n
1. Centers for Medicare and Medicaid Services (2001). Conditions for coverage
of outpatient physical therapy, occupational therapy and speech pathology services,
Chapter 2, 271.1 Conditions of coverage. Comprehensive outpatient rehabilitation
facility and community mental health center manual, www.hcfa.gov.
Bob Thomas is a geriatric physical therapist and currently serves as director of operations for Avamere Rehab in Oregon and Washington. He also lectures nationally for Great Seminars on rehab solutions for the institutionalized elderly.