What is the definition of progress?  According to ‘The Free Dictionary by Farlex” online, the definition of the word ‘Progress’ as a noun is:

1. Movement, as toward a goal; advance
2. Development of growth
3. Steady improvement
4. A ceremonial journey made by a sovereign through his or her realm

The definition of ‘Progress’ as a verb is:

1. To advance, proceed
2. To advance toward a higher or better state; improve steadily
3. To increase in scope or severity, as a disease taking an unfavorable course

In therapy, we use the word “Progress” when talking about the gains a resident/patient is making toward functional improvements.  It has been drilled in our heads for years from Fiscal Intermediaries/MACs that we must show significant functional improvement week to week in therapy and if the resident/patient doesn’t make those significant gains, then the service is no longer necessary.  I have been in the field for over 20 years and this philosophy is embedded into my soul.  Of course I want my residents/patients under my care to make significant functional improvements week to week—that’s why I became a health care provider—To Make People Better!

So, now since the Jimmo v. Sebelius  case , “Progress” (Improvement Standard) has been topic of discussion in therapy departments and SNFs relating to therapy discontinuation.  It is unfortunate that the Fiscal Intermediaries/MACs’ interpretation of the regulation caused the therapy world to focus so much on “Progress”.  The Medicare statute and regulations have never supported the position of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a resident’s/patient’s condition.  The lack of restoration potential alone in itself does not serve as the basis for denying coverage of services.

The bottom line is whether the services are reasonable and necessity and require the skills of a therapist to treat the underlying impairments/functional deficits, not the potential of the resident/patient to restore their function.

Let’s look at the regulation.  The Medicare Benefit Policy Manual, Chapter 15, Section 220.2C: skilled therapy states, Rehabilitative therapy occurs when the skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.” “The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition.  In the case of a progressive degenerative disease, for example, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function.  The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel without the supervision of qualified professionals.”

We can talk about the regulation as it stands now but CMS is currently updating their manuals to provide clarification and detail to reinforce the intent of the policy.  These revisions will clarify that the coverage of therapy “……does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”

I think it is important for providers to discuss the clinical case with their residents/patients/family members reflecting whether the skills of a therapist are vital to treat the condition and/or whether or not the need for skilled care under Medicare guidelines still exist.

In this bloggers personal opinion, I can say that I am happy to know that CMS will be conducting an educational campaign with the Intermediary’s/MACs to ensure they understand the policy……too bad the clarification didn’t occur sooner.

Gina Tomcsik

Director of Compliance

Functional Pathways