Frequently Asked Questions for Maintenance Therapy
1. Can we admit someone directly to maintenance therapy?
Yes, but there must be evidence that the services are reasonable and necessary -- that the specialized skills, knowledge, and judgment of a qualified therapist are required to develop a maintenance program. And if a patient was recently on service, why that maintenance plan was not developed in that episode.
2. Can we have one discipline treating for maintenance therapy and another treating for restorative?
Yes, maintenance therapy can be performed by one discipline while another one is treating under restorative a restorative plan of care.
3. If a patient goes into the hospital while receiving maintenance therapy, when they come back on services do we need to transition them back to restorative care?
Yes and no, upon re-evaluation post-hospital if they have not had a significant decline then you should continue treating under maintenance. If they had a significant decline then they would go back to restorative and POC modified with physician approval. Appropriate documentation must be present to support either outcome.
4. Is there a scenario where it is reasonable to switch between maintenance therapy and restorative in a single episode?
Yes, there may be a situation where a patient declines within a maintenance therapy treatment plan due to an event or circumstance; thereby restoring a patient to a maintenance level of function is appropriate. We would need to ensure that our problem statements/interventions and billing reflect this scenario accurately.
5. What about maintenance therapy with our memory impaired population?
In order to satisfy the regulatory requirements, it would need to be evident that there is a need to continue to assess the effectiveness and make adjustments to the HEP or caregiver training to slow decline. Or, the patient requires sophisticated therapy techniques to carry out the therapy AND/OR the medical condition of the patient is so complex that the skills of a therapist (not an assistant) must provide the treatment. Maintenance therapy documentation that paints a picture of a therapist seeing a patient for ambulation, or to perform exercises, or ADL’s with, is typically not enough to meet the criteria for maintenance in and of itself without explaining the complex techniques required of a therapist. Lack of a caregiver, lack of willingness of a caregiver, and/or lack of patient compliance does not meet the criteria for maintenance therapy. Skilled techniques for maintenance therapy for memory care might be Montessori techniques, spaced retrieval, etc., to make the case for the skilled maintenance therapy need.
6. What if I have a patient that I know will decline after my restorative plan is completed because they are not compliant with the education and training I have provided nor do they have a caregiver, and I have a planned discharged for the patient?
Services are not covered or considered skilled maintenance therapy just because a competent, skilled caregiver is not available to furnish the services and so a therapist must perform them. This would not be a covered maintenance therapy benefit unless:
1) the patient requires complex and sophisticated treatment techniques that must be performed by a therapist,
2) the patient has a complex medical condition requiring a therapist to provide the intervention because of the complexities of the medical condition,
3) ongoing training /modification of caregivers or a home exercise program is required in order to maintain, prevent or slow patient decline.
7. What is an appropriate frequency for maintenance therapy?
Just as the policy guidance doesn’t mandate frequencies for a restorative POC, there is no mandate for a maintenance POC. Your frequency will depend on the goals you have to maintain, prevent, or slow decline and the patient characteristics.
8. My patient needs assistance walking or with his exercise program because he will not do it when his therapist is not there. Without these consistent treatments, I know my patient will decline. Is this a covered service under the maintenance therapy plan of care?
In the example given, there does not appear to be evidence of a skilled need that requires complex or sophisticated interventions or that the patient suffers from a medically complex issue requiring a therapist. Finally, under “Criteria 2,” there does not appear to be evidence that the therapist is evaluating the need for HEP modification. Section 40.2 of the Medicare Benefit Policy Manual specifically states that, “services are not covered or considered skilled maintenance therapy just because a competent, skilled caregiver is not available to furnish the services and so a therapist performs them.”