It is not news to anyone that skilled nursing facilities, in particular therapy services, are under an enormous amount of scrutiny these days and are being inundated with CMS initiatives and regulations that often contradict one another.   A few examples include the increasing ZPIC audits, therapy thresholds and manual medical review (both prepayment and post payment) by the RACs, functional limitation requirements and Jimmo vs. Sebelius.

Providers are reaching out to me asking the hard questions:

  1. Should therapy be limited for residents who reach the $3700 threshold for Part B therapy services?
  2. What do you think the outcome will be from CMS’ evaluation of functional limitations when coding becomes mandatory on July 1st?
  3. Does Jimmo vs. Sebelius mean we can start providing maintenance therapy now?

I have to admit, I have been urging caution in providing maintenance therapy services in light of the contradictory components of the Part B threshold and functional limitation reporting.  I also am skeptical given the fact that CMS has until January 2014 to update the Medicare manuals and initiate training for the MACs. AHCA has even urged caution in providing these services.  The Medicare Advocacy Center is, however, telling beneficiaries that they entitled to maintenance therapy now.  So what is the therapist to do?

Well the answer is really what we are always telling our therapists and that is what does the resident need.  If a therapist does an evaluation that supports a clinical need for therapy services that are reasonable and necessary in accordance with Medicare guidelines and that require the skills of a licensed therapist then we must provide the services.  We must, of course, also remember that we bear the burden of documenting the services that we are providing to a resident in a way that will stand the test of the appeal process—because if you build it (treat)—then they will come (the auditors).  But we must never let the fear of random audits get in the way of what is clinically right for us to do.  Advocating for the resident is always the right way to proceed!