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PTA Blog Talk

Jimmo v. Sebelius

Published January 23, 2014 10:53 PM by Jason Marketti

By January 23, 2014, CMS will have completed the manual revisions and educational campaign regarding this case. Frankly I haven't seen much about the educational aspect of the case and I had to look up the revisions they made on various websites to get a better overview and understanding of the information involved.

The goal of the settlement was to make sure claims are adjudicated in accordance with Medicare policies so beneficiaries receive the full coverage to which they are entitled. Medicare has never supported an "Improvement Standard" in determining whether skilled care is appropriate. A patient's lack of potential to recover should not serve as a basis for denying coverage, but a determination on whether skilled care is required is the determining factor. (42 CFR 409.32(c))

Essentially, a PT has to make the assessment and determine whether the skills and knowledge of a therapist will be needed to see a patient who doesn't have the potential to recover from his illness, accident or disease. Terminal cancer patients and heavily involved CVA patients come to mind. Some therapy department may discharge a patient if there's no progress in a month or two but now this case should shed light on the coverage Medicare beneficiaries are eligible to receive.

A couple of provisions stipulate that only a "qualified physical therapist" be allowed to perform the skilled service. Heat, ultrasound, paraffin baths and whirlpools are among those services only a PT can do. Therapeutic exercises and activities should be done by or under the supervision of a PT or OT. (43 CFR 409.33)

As I've been told, expect every document you write in to be reviewed and adjudicated somewhere. To establish coverage, documentation should be relevant in identifying markers and clinical information to effectively support skilled services is needed. No more of the vague and insufficient explanations of how the patient "tolerated the treatment well."

This ruling should also open doors for patients and family members alike. We should expect more appeals from beneficiaries when PT services are discontinued. We can then allow CMS, the reviewers, family, patients, and the facility to hash out whether a patient's care is, by definition, "services which qualify as skilled rehabilitation services."

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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