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When Did “Maintenance” Become a Bad Word?
February 2013
Presented by: Cindy Krafft MS, PT
Rhonda Will, RN, BS, COS-C, BCHH-C
Fazzi Associates, Inc.
243 King Street, Suite 246 Northampton, MA 01060
413-584-5300 Fax: 413-584-0220
www.fazzi.com
Instructions and Handouts for: When Did “Maintenance” Become a Bad Word?
February 14, 2013
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Eastern Standard Time
3:00 PM to 4:30 PM
Central Standard Time
2:00 PM to 3:30 PM
Mountain Standard Time
1:00 AM to 2:30 PM
Pacific Standard Time
12:00 PM to 1:30 PM
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When Did “Maintenance” Become a Bad Word?
Cindy Krafft PT, MS
Rhonda Will, RN, BS, COS-C, BCHH-C
Fazzi Associates, Inc.
©2013
Objectives
• Define the relevance and clinical applications of management and evaluation and maintenance therapy;
• Discuss aspects of skilled clinical care and the correct application of G Codes for billing;
• Examine the critical documentation elements to support the clinical practices of management and evaluation and maintenance therapy.
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Maintenance Myths
• Maintenance is never done in home health.
• We can now see people indefinitely.
• Home Programs = Maintenance Therapy.
• Therapy Discharge = Maintenance Code.
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New Program?
• Maintenance is NOT a new Medicare benefit.
• PPS 2011 did NOT change coverage criteria.
• The requirement of “skill” still exists.
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Skilled Therapy
• Assessment
• Planning, Implementing and Supervision of Therapeutic Program
• Medicare Benefit Policy Manual, Chapter 7, Sec. 40.2
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Reasonable and NecessaryTherapy Services
• To the treatment of the patient's illness or injury or
• To the restoration or maintenance of function affected by the patient's illness or injury.
• It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient's overall condition, skilled management of the services provided is needed.
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Management and Evaluation and Therapy Maintenance Program
• The development, implementation, management, and evaluation of a patient care plan based on the physician's orders constitute skilled therapy services when, because of the patient's condition, those activities require the skills of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety. Where the skills of a therapist are needed to manage and periodically re-evaluate the appropriateness of a maintenance program because of an identified danger to the patient, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part of the maintenance program.
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PPS 2011: Maintenance = Skilled
• “Require the specialized skills, knowledge, and judgment of the qualified therapist to design or establisha safe and effective maintenance program”
• “The unique clinical conditions of a patient may require the specialized skills of a qualified therapist to performa safe and effective maintenance program”
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Therapy G Codes“Maintenance”
G0159
Physical Therapist in the home health setting, in the establishment or
delivery of a safe and effective physical therapy maintenance
program, each 15 minutes.
G0160
Occupational Therapist in the home health setting, in the
establishment or delivery of a safe and effective occupational therapy
maintenance program, each 15 minutes.
G0161
Speech‐Language Pathologist in the home health setting, in the
establishment or delivery of a safe and effective speech‐language
pathology maintenance program, each 15 minutes.
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Diagnosis?
• “A prescriptive definition of these sorts of conditions, such as a listing of specific disease states that provide subtext for these descriptions is impractical, as each patient’s recovery from illness is based on unique characteristics.”
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Skilled Therapy Services
• While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel.
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Who Decides?
• “We believe that rehabilitation professionals, by virtue of their education and experience, are typically able to determine when a functional impairment could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.”
• “We expect rehabilitation professionals to be able to recognize when their skills are appropriate to promote recovery.”
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Focus of Care
Restorative Therapy
• Intent is to improve the patient’s ability to function.
• Qualified therapist establishes the plan of care and completes required reassessments.
• Therapy assistants CAN provide care
Maintenance Therapy
• Intent is to prevent further loss of function.
• Qualified therapist establishes the plan of care and completes the required reassessments.
• Therapy assistants CANNOT provide care
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Establishing a Program
• Determine current status of the patient.
• Assess rehabilitation potential.
• Create program based on patient specific needs.
• Ascertain teaching needs of patient and caregiver.
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Skilled Assessment
Measurements
• ROM• Strength• Balance• Vision• Pain• Sensation• Communication• Cognition• Environment• Equipment
Functional Impact
• Ambulation• Transfers• Bathing• Dressing• Toileting• Incontinence• Medication Management• Swallowing• Home Management
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What Does a Therapist See?
• “Gait Deficits”o Patient 1 – Visual and cognitive issueso Patient 2 – Leg length discrepancy and pain.
• “ADL Deficits”o Patient 3 – Anxiety and lack of transfer bencho Patient 4 – Balance and arm in a sling
• “Swallowing Deficits”o Patient 5 – Posture and muscular weaknesso Patient 6 – Attention and memory
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Examples – “Why” Therapy
• Patient considered at risk for pressure ulcers due to current level of immobility. Transfer and gait training will focus on necessary position changes to decrease risk.
• Patient’s daughter requires training in lower extremity positioning techniques and PROM to ensure correct follow through.
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Delivering Care
• Biggest risk is repetitive documentation without showing skill.
• Defend why a therapist must be involved with each visit.
• Specifically address the plan to transition care to someone else.
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Skilled Interventions
• Intervention = “interference”.
• Disruption of the current process.
• Puts the patient on a different path.
• Driven by the assessment findings.
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Examples – “Why” Therapy
• Transfer training to decrease workload on caregiver.
• Upper extremity stretching techniques taught to caregiver to prevent contracture and continue participation in grooming.
• Education regarding correct use of thickener to decrease risk of aspiration.
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How Many Visits?
• There are no specific minimum or maximum number of visits.
• Defining issue is the level of skill required.
• “Caregiver Ed”
• Must maintain clarity regarding the true needs of the patient.
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Reasonable and Necessary?
• “If an individual’s expected restorative potential would be insignificant in relation to the extent and duration of therapy services required to achieve such potential, therapy would not be considered reasonable and necessary, and thus would not be covered.”
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Nursing Services for How Long?
• The determination of whether a patient needs skilled nursing care should be based solely upon the patient's unique condition and individual needs, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time. In addition, skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable.
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Key Medicare Coverage Criteria
• Jimmo v. Sebelius
• Demonstrated need for skilled care regardless of whether there is a recovery prognosis
• Need care to maintain their current condition
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Skilled Nursing Service
• Must be provided by a registered nurse or a licensed practical (vocational) nurse under the supervision of a registered nurse to be safe and effective
• Consider both the inherent complexity of the service and the condition of the patient
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Reasonable and Necessary
• For the diagnosis and treatment of the patient's illness or injury within the context of the patient's unique medical condition.
• Consistent with the nature and severity of the illness or injury, the patient's particular medical needs
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Skilled Nursing Services
• Observation and Assessment (O & A) of the Patient's Condition o Only the specialized skills of a medical professional can determine
patient's status
• Management and Evaluation (M & E) of a Patient Care Plan o where underlying conditions or complications require that only a
registered nurse can ensure that essential non-skilled care is achieving its purpose
• Teaching and Training Activities o When skilled nursing personnel required to teach a patient, the patient's
family, or caregivers how to manage the treatment regimen
• Medicare Benefit Policy Manual, Chapter 7, Sec. 40.1
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Reasonable and NecessaryManagement and Evaluation
• When the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.
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An aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted, but increasing mobility. Although a properly instructed person could perform any of the required services, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the combination of the patient's condition, age, and immobility create a high potential for serious complications, such an understanding is essential to ensure the patient's recovery and safety.
The management of this plan of care requires skilled nursing personnel until the patient's treatment regimen is essentially stabilized.
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Billing
• Claims report service/visit in 15 min increments to reflect the total time of the visit
• G code reflects the service for which the most time was spent during that visit
• Medicare Claims Processing Manual, Ch. 10
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Nursing G Codes
G0154
Direct skilled services of a licensed nurse (RN or LPN) in the home health or
hospice setting, each 15 minutes.
G0162
Skilled services by a licensed nurse (RN only) for management and evaluation of
the plan of care, each 15 minutes (the patient’s underlying condition or
complication requires and RN to ensure that essential non‐skilled care achieves
its purpose in the home health or hospice setting).
G0163
Skilled services of a licensed nurse (RN or LPN) for the observation and
assessment of the patient’s condition, each 15 minutes (the change in the
patient’s condition requires skilled nursing personnel to identify and evaluate
the patient’s need for possible modification of treatment in the home health or
hospice setting.
G0164
Skilled services of a licensed nurse (RN or LPN), in the training and/or education
of a patient or family member, in the home health or hospice setting, each 15
minutes
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Skilled Nursing
• G0154 Direct skilled services of RN or LPN
• Examples:o Wound care
o Injection
o Catheterization
o Ostomy care
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Skilled Nursing
• G0164 Skilled service by RN or LPN for training and/or educating patient or family member
• Examples:o Education about new medications
o Education about self injecting a medication
o Training to care for a colostomy
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Skilled Nursing
• G0162 Skilled service by RN for management and evaluation of the plan of care.
• RN supervision of non-skilled services.
• This is not an evaluation visit
• G0163 Skilled service by RN or LPN for observation and assessment of the patient’s condition
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Evaluation
We’d love to hear your feedback on the training. Please use the link below to take our survey. Certificates of attendance will be delivered following completion of the survey. To complete the survey, go to:
https://www.research.net/s/2NNMNSC
If you have any questions, please contact Katherine Butler at [email protected].
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