We have a patient who has achieved ambulation in the hallways at supervision level using a walker. Our new case manager is insistent that we discharge as soon as possible, or our services could be denied by Medicare. The patient wants to return to PLOF, independent ambulation, so her therapists do not feel a discharge is appropriate at this time. Would this claim be at risk for denial?




Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether the services are, in fact, reasonable and necessary for the treatment of a patient’s illness or injury. The documentation must show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals. These guidelines must be applied to each case to determine whether skilled care is appropriate. A few questions that may be discussed during the IDT meeting include, but are not limited to:

      • What is the patient’s fall risk measured in objective terms? Are their measurable gait deviations that contribute to fall risk?
      • Will the patient have 24 hour supervision upon return home? Is a home assessment appropriate?
      • Is the resident’s performance level consistent throughout the day? Is there a caregiver at home that will be able to assist during times of day (e.g. evening hours) when the patient may require more assistance?
      • What is therapy currently doing that could not reasonably be carried out by non-skilled personnel?
      • What are the risks associated with a premature discharge?
      • Would outpatient or home health therapy be sufficient to meet the patient’s needs?
      • Is the relevant information that guided the decision to continue or discharge skilled services well documented in the EMR?

CMS gives guidance on SNF services provided as a “practical matter” (Ch 8 Medicare Benefit Policy Manual; 30.7) to determine whether the daily skilled care can only be provided in a SNF on an inpatient basis. For example, the availability of capable and willing family or the feasibility of obtaining other assistance for the patient at home should be considered. Even though needed daily skilled services might be available on an outpatient or home care basis, as a practical matter, the care can be furnished only in the SNF if home care would be ineffective because the patient would have insufficient assistance at home to reside there safely.

Example: A patient undergoing skilled physical therapy can walk only with supervision but has a reasonable potential to learn to walk independently with further training. Further daily skilled therapy is available on an outpatient or home care basis, but the patient would be at risk for further injury from falling, because sufficient supervision and assistance could not be arranged for the patient in his home. In these circumstances, the physical therapy services as a practical matter can be provided effectively only in the inpatient setting.

Keep in mind that physical therapy services should meet the following conditions (Ch 8 Medicare Benefit Policy Manual;

      • The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist;
      • The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or, the services must be necessary for the establishment of a safe and effective maintenance program; or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program.
      • The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patient’s condition; and,
      • The services must be reasonable and necessary for the treatment of the patient’s condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable.

Some SNF inpatients do not require skilled physical therapy services but do require services, which are routine in nature. When services can be safely and effectively performed by supportive personnel, such as aides or nursing personnel, without the supervision of a physical therapist, they do not constitute skilled physical therapy. Additionally, services involving activities for the general good and welfare of the patient (e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation) do not constitute skilled physical therapy.

Additional guidance related to reasonable and necessary therapy services (Ch 15 Medicare Benefit Policy Manual; 220.2):

      • A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.
      • The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional. Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.
      • While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot 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 nonskilled personnel.

Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services

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