Skilled Physical Therapy Tied to Medicare Improvement Standard

Many physical therapists still believe that Medicare will not pay for therapy that does not lead to a change in functional status.

This is NOT true.

The Medicare Improvement Standard...

"...has a particularly devastating effect on patients with chronic conditions such as

• Multiple Sclerosis
• Alzheimer's disease
• ALS
• Parkinson's disease
• paralysis."

According to the Center for Medicare Advocacy:

"People with chronic conditions and long-term illnesses are often denied Medicare coverage because their medical condition will not supposedly:

• Improve on functional status scores
• They need maintenance services only
• They have plateaued
• They are chronic and stable

These reasons are referred to as the Medicare "Improvement Standard."  

Medicare is often the only insurance for this population, so, unfortunately, Medicare coverage denials can result in the loss of necessary health care.

This short podcast (7:11) from the Center for Medicare Advocacy may help you understand some of the issues these patients face in trying to get their necessary healthcare.

Unfortunately, due the the complex nature of Medicare documentation many physical therapists must waste valuable time learning how to document "skilled physical therapy" rather than actually treating patients.

I have found that patients often encounter barriers from their own physical therapists who may be uncertain or afraid to append the -KX modifier when care beyond the $1,880 is clearly necessary.

If patient progress is slow, marked by significant setbacks or difficult to measure the physical therapist may refuse to continue treating the patient.

Even though the patients' Medicare benefit allows physical therapy for these conditions.

The physical therapists' reluctance is due to fear of a Medicare Audit.

The Center for Medicare Advocacy has pressed a class action lawsuit against Kathleen Sebelius that may force Medicare to acknowledge its illegal "Improvement Standard" so that physical therapists may gain some clarification on our documentation requirements.

Please share tips on how YOU document exceptions to the $1,880 physical therapy cap.