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FOTO Rehab Outcomes Blog

Medicare and Maintenance Therapy

 Four years ago Glenda Jimmo filed a case against Health and Human Services in the US District Court in Vermont. The final outcome is what many of us are familiar is the Jimmo Agreement. Centers for Medicare and Medicaid Services (CMS) have been going through the completion of the various aspects of the agreement. As of August 2017, CMS created a special web page informing all about this agreement.

For many of us in the rehabilitation world, we have it engrained in our brains that in order for services to be covered by the federal payer OR an advantage plan, the patient has to demonstrate improvement. We need to wrap our heads around the fact that we've been led to believe something that isn't true. Reality is that the federal plan covers maintenance therapy. If a patient's status can be maintained with services OR if decline can be prevented with services, then it is perfectly acceptable to provide services that will be paid by the federal insurance plan.

What do we need to have in place in the event our services are under scrutiny?

I think one area that is really important to have a handle on for each patient are the comorbidities that will affect outcomes. For my practice, often times the patients that fall into maintenance therapy typically have quite a few comorbidities that I need to keep in mind as I create their care plans. 

These are the comorbidities that FOTO listed for one of my patients. The actual diagnosis of inclusion body myositis, gait instability and multiple falls are a piece of the missing story.

comorbidities.jpg Another aspect that is redundant in light of the new evaluative codes for 2017 is the patient's complexity. For this patient, based on the reported health problems, FOTO did provide a level of complexity that I was to consider when choosing my evaluation code.


Patient reported outcome measures will be great assets to use to track functional level for these individuals. In this particular case, the focus won't be on a predicted outcome. The focus will be on tracking the patient's level of function and hopefully maintaining it OR noting changes in condition that may be related to other treatments, your own treatments or adverse events in the patient's life. For the above patient, I didn't believe the predicted outcome would happen. The gentleman's diagnosis is not in a category in which a high amount of anticipated improvement will occur. Although I know this, I still capture his functional ability with FOTO.

initial status.jpg

Although a high amount of change is not expected, I still track functional change every 4 weeks to determine how the patient believes he is doing. Now in this case, the patient was to begin services and then fell. He was not able to attend in June because of his injury. He waited and began services at the end of July.  You can immediately see how his function changed after a fall. Although the below change appears pretty darn good after his injurious fall, he may be overzealous in his perception. If I had a video, you'd all be nodding your heads in agreement with me. Actually, I do have a video... spoiler alert.

 status update.jpg

Besides using FOTO's functional score as a measurement, I also use other measurements to create a broader picture - along with being a check and balance system for how a patient is perceiving function. What other areas are important to the patient? I always use the Patient Specific Functional Scale and often times with individuals who are at risk of falling, I also use the Activities-Specific Balance Confidence Scale.

additional tools.jpgI believe this particular patient became somewhat confused when responding to the Patient Specific Functional Scale. This gentleman is not able to perform any of his goals easily or normally. I am pretty sure that he flip-flopped his responses when he answered the questions. 

Although most electronic medical records don't have the capacity to include video within a daily note due to the storage size required, that doesn't mean that you should rule out the value of video. Just this snapshot provides a bit more of the story of how this patient is presenting at today's date. (Yes, this patient allowed video sharing.)

 Another aspect to remember is within your daily and progress documentation. You can document the amount of verbal cues required to perform tasks. You can keep in mind the patient's ability to complete multi-step tasks. What about the amount of physical assistance required to be able to perform the activities in the clinic? It's helpful to document information about treatments provided by other professionals: medication changes... hospitalizations... injections. At times pain and fatigue come into play with the patient's ability to perform in the clinic. For many of these patients, I am also assessing vitals and oxygen saturation to monitor their physical response to activities. When activities are changed due to the patient's presentation for that treatment session, it's wise to document the change in presentation and how it was addressed. 

All of the above recommendations will help to demonstrate why skilled services are required. Even though maintenance therapy seems like it would be an easy task, often times, for the individuals that need it the most, clinicians need to be tracking, thinking and have the ability to be flexible due to the ever changing presentation these individuals typically have.

Until next time,