In October, 2012, the settlement agreement in the Jimmo v. Sebelius class action lawsuit was reached. The plaintiffs in this case were seeking to challenge denials of Medicare claims based on lack of progress in patient therapy care. This settlement agreement revises the accepted industry definition of covered services and opens up conversation and debate about maintenance therapy as a home health service and has many scratching their heads wondering just what the heck is home health maintenance therapy?

According to the local coverage determination for Home Health Physical Therapy, “If the patient’s clinical condition requires the specialized skill, knowledge and judgment of a qualified therapist to design or establish a maintenance (sic) program relatd (sic) to the patient’s illness or injury, in order to ensure the safety of the patient and the effectiveness of the program, such services are covered.”  In a nutshell, home health maintenance therapy is a service provided by a qualified Physical Therapist, Occupational Therapist or Speech Language Pathologist where periodic monitoring or adjustment of a care plan is required. For example, a Physical Therapist determines that his services are no longer required on a regular basis but needs to choose a home exercise program based on his clinical judgment that may or may not be the most beneficial to the patient in the long term. He may decide to transition the patient to a maintenance program where the patient performs the exercises on his own with the assistance of caregivers or family and the qualified therapist visits the patient a few times a month to ensure that the patient’s level of function continues to improve or stabilizes and reduces the possibility of a decline in function.

Maintenance therapy can only be provided by qualified therapists – Physical Therapists, Occupational Therapists or Speech Language Pathologists. Due to the complexity and sophistication of therapy procedures required, a PTA or COTA is not qualified to evaluate or make changes to a treatment plan in home health.

And maintenance therapy is coded differently on the PPS end of episode claim submitted by home health providers so it is important that these services are identified on each clinical note so that they will be billed appropriately.

  • G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes
  • G0160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
  • G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes

Unfortunately, there is no industry standard as to how many visits or how often is appropriate for a therapy maintenance case. Most consultants will say that the patient’s clinical condition, the patient’s support network and the complexity of the treatment all must be taken into consideration by the clinician to determine the reasonable amount, frequency and duration of services.

As the effects of the Jimmo v. Sebelius settlement are debated and clarified, there will certainly be more updates to existing legislation in the coming months. We at Pragma-IT will continue to monitor information as it is released and provide updates where needed.

For more information about therapy maintenance, please see:

CMS local coverage determinations on Physical Therapy, Occupational Therapy and Speech Language Pathology

Jimmo v. Sebelius settlement and the effects on home health – by Arnie Cisneros from Home Health Strategic Management (HHSM)

Class Action Lawsuit Against the Federal Government Terminates Medicare Improvement Standard from American Academy of Physical Medicine and Rehabilitation

The New York Times: Settlement Eases Rules for Some Medicare Patients