Whoa! Slow Down! (the disease process….)
Many thanks to one of my internet friends, Guy Davis who works with the HomeSight Programs, I have received a Palmetto notice that I obviously missed earlier. This one, unlike thousands of others, is actually important. It tells us that skilled services can continue to be provided as long as they are required for the maintenance of the patients current condition or to slow down the progress of a disease state. Based on the Jimmo settlement, there are now updates to the Medicare Coverage Benefits Manual for home health that read:
…Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition. Medicare Benefit Policy Manual, Ch. 7, 20.1.2
…Skilled Nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. … MBPM, Ch. 7, 40.1.1
Maintenance Therapy – Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy services. … MBPM, Ch. 7, 40.2.2.E
This does not mean that you can adopt patients for life or continue to teach and re-teach the same material. It does not extend Observation and Assessment beyond three weeks if there is no documented real potential of an exacerbation.
It does mean that patients who respond to therapy and suffer less pain because of therapy may continue to receive it as long the therapy is of a complexity that it can only be rendered by a skilled therapist.
The case that comes to mind is one that was denied a couple of years ago. The patient suffered from multiple skeletal deformities which compromised the space in her thoracic cavity and gut for her organs. Without regular therapy, she would have spasms to the extent that she fell off her scooter. Nobody else could perform the therapy which consisted of deep tissue massage among other modalities because of the skeletal deformities.
This is an extreme case but maybe not so extreme in light of Jimmo. Remember, you can see a patient to maintain a condition or slow the progress but ONLY when the complexities of the skill require a therapist.
Does anyone have any patients they think they may have discharged prematurely in the past that met the Jimmo criteria?
I wonder about some wounds that simply will not heal. If it requires the skills of a nurse to safely render care to prevent infection or expansion in wound surface area, would it now be covered? Speaking of Guy and Homesight, what about the visually impaired patient who requires regular checks for macular degeneration to quickly identify opportunities for laser therapy and thus, prevent further deterioration?
I do not expect any colleagues to take advantage of these changes to the coverage manual without bringing needed benefits to the patient. I think if you take the time to read my blog, you passed up that level of sleaze a long time ago. On the other hand, I have been heartsick at some discharges in the past where a patient was not going anywhere. It was like they were suddenly stable at the lowest level of functioning they could reach. They needed home health nursing or therapy but according to our guidelines, they simply did not qualify.
Many thanks to those who fought long and hard for the Jimmo settlement. It isn’t going to open the doors for abuse of the Medicare benefit but it will make a world of difference for a small group of patients who genuinely need us.