It’s been more than 5 years since the landmark Jimmo V Sebelius case. That case is arguably the most important thing to happen to therapy delivery in skilled nursing during the last decade. However, it seems like no one is talking about it and many aren’t even aware of what it means. Let’s hit some of the highlights, courtesy of the Center for Medicare Advocacy.
First, some background: the Jimmo v Sebelius case was brought to challenge the idea that CMS and its contractors could deny a therapy claim based on an “Improvement Standard”. Essentially Jimmo argued that improvement wasn’t always the goal of therapy and can’t be the basis for denial. The case was settled so the court never ruled on the argument. As part of the settlement, CMS clarified a few things.
Here are a few selected excerpts from the Center for Medicare Advocacy FAQ on the case: (emphasis added)
Question: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve?
Answer: No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing facilities, home health, and outpatient therapy, when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration.
Question: Is it fraud for a skilled nursing facility, home health agency, or outpatient therapy provider to continue to provide skilled nursing or skilled therapy services to a patient who is not improving?
Answer: No. As long as the Jimmo Settlement is followed, the patient continues to need professional nursing or professional therapy services to maintain the patient’s condition or to prevent or slow the patient’s decline or deterioration, and all relevant coverage criteria for the particular health care setting are met, Medicare covers the services and the health care provider is not committing fraud.
Question: If a patient has plateaued, does Medicare coverage for skilled nursing or skilled therapy services stop, unless the patient deteriorates?
Answer: No. The Medicare program does not require a patient to decline before covering medically necessary skilled nursing or skilled therapy. If a patient is no longer improving and the basis of Medicare coverage is expected to shift to maintenance, the nurse or therapist must assess the patient and develop a plan of care to reflect the new maintenance goals. The nurse or therapist must document the maintenance goals in the plan of care and in the nursing or therapy notes.
Question: Does the Jimmo Settlement apply to patients who have dementia?
Answer: Yes. Dementia is not a disqualifying condition for Medicare coverage. If the patient needs skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s decline or deterioration, Medicare covers the therapy services, as long as all other coverage criteria are met. Skilled professional therapists are trained to work with patients who have dementia.
Question: What are some appropriate goals for maintenance therapy?
Answer: Maintenance therapy goals include preventing unnecessary, avoidable complications from a chronic condition, such as deconditioning, muscle weakness from lack of mobility, and muscle contractures. Maintenance therapy goals also include reducing fatigue, promoting safety, and maintaining strength and flexibility.
For a patient with a progressive neurologic condition, appropriate maintenance therapy goals include maintaining joint flexibility, preventing contractures, reducing the risk for skin breakdown, and ensuring appropriate positioning.
As you can see, there are a lot of things in the FAQ that challenge ideas you hear every day. The FAQ is a good read in its entirety. Slowing the progress of a condition or preventing unnecessary falls is a noble goal and covered by Medicare.