Tuesday, January 21, 2014

Improvement Standard Updates


Complying with the court settlement in Jimmo v. Sebelius, which overturned the so-called ‘improvement standard,” CMS released revised program manual guidance and has initiated its agreed to outreach and education efforts, namely a Change Request (CR) 8458 to the Medicare Benefit Policy Manual with an accompanying MLN Matters article (MM8458).In addition, CMS held a National Provider Call to provide an overview of the clarifications to the Medicare program manual.

On January 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the Jimmo v. Sebelius (Jimmo) case in which the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled nursing facility, home health, and outpatient therapy benefits). The settlement agreement contained specific steps that CMS must implement, including issuing clarifications to existing program guidance and new educational material on this subject.

The program manuals now state that coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

Major aspects of the manual clarifications include the following:

An “Improvement Standard” is not to be applied in determining Medicare coverage for maintenance claims that require skilled care. Such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying necessity of the services themselves.

Enhanced guidance on appropriate documentation now includes material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. CMS provides that such documentation serves as the means by which a provider can establish and a Medicare contractor would be able to confirm, that skilled care is needed and received in a given case.

CMS’ position is that there is no expansion of coverage. Its intent is to clarify Medicare’s longstanding policy that coverage cannot be denied based on the absence of potential for improvement or restoration. Thus, CMS takes the position that the revised manual material does not represent an expansion of coverage, but rather, provides clarifications that are intended to help ensure that claims are accurate and appropriate in accordance with the existing policy

Following are some brief notes from the “CMS National Provider Call” on Jimmo:
  • The requirements for skilled nursing or therapy maintenance services are similar. The patient’s medical condition demonstrates that the specialized judgment, knowledge and the skills of the nurse or therapist are necessary. 
  • The Jimmo settlement only addressed the maintenance services coverage requirement. Other coverage requirements remain, such as the 3-day qualifying stay and 100 day benefit limit per spell of illness for SNF Part A, or the therapy caps for Part B. 
  • There is a fairly extensive expansion of documentation requirements. While the manual language does not add new reporting frequency requirements, or specific forms, the documentation needs to be sufficient in order for a Medicare contractor to understand that the provider is meeting the skilled coverage requirement. 
  • CMS indicated that while there is no specific coding requirement to differentiate “restorative” from “maintenance” on the claim, the clinical documentation should clearly identify whether the treatment goals are “restorative” or “maintenance” in nature. 
This LTC Blog article is a brief description of many, but not all, aspects of the Jimmo settlement. Providers should seek professional guidance and not base future actions solely on this material.

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