Most of the time, therapy is understood to be restorative (rehabilitative). For example, a woman may have lymphedema (protein-rich swelling) in her arm. Because of this swelling, she is at risk for progression of her lymphedema (including infection & skin changes). Normal activities such as combing her hair may be more difficult. Therapy is administered & successful in reducing limb size, providing training, etc. She would be measured for a custom compression garment to maintain the state attained &, ideally, be independent at the time of discharge. She would return to see her therapist only if needed. (In the case of lymphedema, a periodic checkup is recommended to monitor tissue, volume & garment state.)
On a few occasions, a person will decline if care is not ongoing. Therapy in this case would be maintenance. For example, an elderly gentleman lives alone & has swelling in both legs. He is at risk for infection & wound development. He also has functional challenges (such as getting into a car). To complicate matters, arthritis makes applying his compression impossible. He may be a candidate for maintenance care by his therapist through Medicare. However, obtaining coverage isn’t that easy. Medicare won’t cover the cost just because a doctor orders ongoing therapy or a therapist provides the care. Several requirements must be met.
In the past, Medicare only covered restorative therapy. They have a long history of denying coverage in cases where a person doesn’t have potential to improve or isn’t showing measurable progress (referred to as the “improvement standard”). This changed in 2013 due to a class-action lawsuit (titled “Jimmo vs Sebelius”). As a result, Medicare released Transmittal 175 which they purported didn’t change their coverage (they stated they have always provided maintenance care). Instead, it was released to clarify existing standards & applies to home health, outpatient & skilled nursing facilities. It states:
- therapy services are covered when a therapist’s assessment of the patient’s condition demonstrates that the therapist’s specialized judgment, knowledge, and skills are necessary to maintain, prevent or slow further deterioration of a person’s condition or functional status
- coverage isn’t dependent upon a patient’s potential for improvement but rather on the beneficiary’s need for skilled care
Assuming a person meets Medicare’s general qualifications for service, for maintenance care to be covered, several items are required (this list is not exhaustive):
- therapist’s assessment must show the skilled need for their specialized services; the services are not able to be safely and effectively carried out by the patient or another person**
- services are shown to be reasonable & necessary for the patient’s illness or injury
- the assessment (which includes the plan of care) must be certified (i.e. signed) by the physician within 30 days (delayed signature is possible with certain criteria)
- therapist must complete a progress note each 10th visit (or 30th calendar day – whichever is less) assessing the patient’s status & appropriateness of continued care
- recertification every 90 days (or before if a plan of care expires)
- additional documentation to justify care may be required (such as visit notes)
- treatment must be performed by a therapist (not an assistant such as an OTA or PTA) in home health or outpatient
- further requirements (such as no stamped signatures, appropriate billing which includes modifier codes when applicable, objective testing, etc.)
Once a patient meets the 2017 therapy cap of $1,980 (for OT or PT/ST combined), if services are still medically reasonable & necessary (& shown to be in the therapist’s documentation & billing), Medicare will continue to provide coverage in threshold amounts of $3,700 (for OT or PT/ST combined). However, they will likely request proof of medical necessity. A therapist may request a patient to sign an Advanced Beneficiary Notice if services are not reasonable & necessary but a patient requests to continue or the therapist has reason to believe coverage may be denied.
If a claim is denied, a person can file an appeal. The process for an appeal is outlined here: https://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html
According to the Local Coverage Determination rules for Texas, “Medicare does not expect to be routinely billed for lymphedema treatments.” Additionally, rules state treatment is only covered when:
- there is a physician-documented diagnosis of lymphedema (primary or secondary)
- the patient has documented signs or symptoms of lymphedema
- the patient or patient caregiver has the ability to understand and comply with the continuation of the treatment regimen at home.
“Documentation must clearly state the need for continued manual therapy beyond 12-18 visits. When the patient or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled THERAPY.”
What can you do to ensure you have needed coverage?
First, contact Congress. Yes – your input will make a difference! Currently, Medicare does not cover compression for lymphedema (despite the Women’s Health & Cancer Rights Act of 1988). Legislation has been introduced & continues to make progress in Congress. You can use this link to easily contact your legislators: Lymphedema Treatment Act.
Second, consider contacting the Center for Medicare Advocacy for help. They are a nonprofit, nonpartisan organization which led the legal action against Medicare in reform for maintenance care (see above “Jimmo vs Sebelius”).
** Per Medicare Transmittal 179, “A service is not considered as a skilled therapy service merely because it is furnished by a therapist…If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct supervision of a therapist, the service cannot be regarded as a skilled therapy service even when a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.”
** Therapists need to be aware that manual lymph drainage (CPT code 97140) & multi-layer compression bandaging (CPT codes 29581-29584) cannot be billed together (according to Noridian – another Medicare contractor which doesn’t have jurisdiction over Texas but their interpretation likely still applies). They state, “Treatment of lymphedema with the application of high compression bandaging continues to be non-covered” except when it is used to teach a patient/caregiver (CPT 97575).” In the latter case, no more than 3 visits should be billed.
Medicare Benefit Policy Manual, Pub 100-02
MLN Matters: MM8458 Revised
Code of Federal Regulations (Title 42, Sections 410.59-410.61; 485.70; 486.150-163)
Medicare.gov: Exceeding Therapy Cap
CMS – Local Coverage Determination (Texas)
Noridian’s Interpretation of CDT