by Liz Seegert

CMS has revised portions of the relevant program manuals used by Medicare contractors as part of a settlement agreement in the case of Jimmo v. Sebelius, a class action lawsuit brought by individual Medicare beneficiaries and national organizations.

Change Request (CR) 8458 updates portions of the Medicare Benefit Policy Manual to clarify key components of SNF, IRF, HH, and OPT coverage requirements and therapy benefits. The goal is to ensure that claims are correctly settled in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled.

In a December 19 conference call, CMS reiterated its clarifications to the Medicare program manuals to reflect their long-standing policy that when skilled services are required in order to provide reasonable and necessary care to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.

Prior to this decision, plaintiffs complained that Medicare contractors were improperly applying “improvement standard” when determining whether to pay claims. Beneficiaries with conditions that are neither curable nor fatal, with no improvement in their prognosis, were being denied coverage, in spite of that fact that skilled nursing care was obviously necessary and appropriate.

The regulations also say that if care can be met safely and effectively through use of non-skilled care, then coverage for skilled care would not be available. We’ve reported previously about specific Medicare contractors seemingly using dated coverage rules to incorrectly deny claims to beneficiaries entitled to skilled care. (Region 4 ZPIC Misinterprets Rules, Draws Ire, HCTR, 11/20/13)

Technology Selection GuideDuring the call, and in a follow up written statement, CMS noted
While an expectation of improvement would be a reasonable criterion to consider when evaluating, for example, a claim in which the goal of treatment is restoring a prior capability, Medicare policy has long recognized that there may also be specific instances where no improvement is expected but skilled care is, nevertheless, required in order to prevent or slow deterioration and maintain a  beneficiary at the maximum practicable level of function.

Providers must clarify whether maintenance or improvement is the care plan goal during the documentation process and whether this can be accomplished through non-skilled care or requires skilled nursing. Any goals changes during the course of treatment must also be documented. Since Medicare only covers skilled maintenance therapy, there must be enough details to show that a case meets the definition – either through complexity of the case or the patient’s condition.

Officials stressed several times that any actions undertaken in connection with this settlement do not represent an expansion or contraction of coverage, but rather serve to clarify existing policy. Home care providers’ bottom line is to ensure that requirements and treatments are appropriately documented, all paperwork is signed by a qualifying referring clinician and all services are correctly coded.

CMS is not looking to deny claims for anyone who needs appropriate skilled services when improvement is not expected. Rather, they want to be sure they are not paying for skilled caregivers if unskilled workers can provide the services.

©2014 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved.
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