- Outpatient Occupational and Physical Therapy Services Billing Guide
- Introduction to Outpatient OT and PT Services
- Outpatient Occupational and Physical Therapy Coverage
- Caregiver Training Services
- KX Modifier Threshold
- 2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring
- Annual Update to the Therapy Code List
- Targeted Medical Review
- Functional Reporting - Using the G Codes
- What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
- Maintenance Programs
- Multiple Procedure Payment Reduction
- The National Correct Coding Initiative
- Comprehensive Error Rate Testing Program
- Recovery Auditor
- Common Billing Errors and Remittance Message
- Medical Review Therapy Documentation Checklist for Additional Development Request Letters
- Common Questions and Answers
- Related Content
- Related Articles
Outpatient OT and PT Services Billing Guide
Maintenance Programs
Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
Establishment/Design of Maintenance Programs
If the specialized skill, knowledge and judgment of a qualified therapist are required to establish/design a maintenance program to maintain the patient’s condition or to prevent or slow further deterioration, the establishment/design of a maintenance program by a qualified therapist may be covered.
If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction may be covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments may be covered.
Once a maintenance program is established, coverage of therapy services to carry out a maintenance program is also determined by the patient's need for skilled care. A maintenance program can generally be performed by the patient alone or with the assistance of a family member, caregiver or unskilled personnel would not be covered. However, skilled therapy services may be covered when an individualized assessment of the patient’s clinical condition demonstrates that a qualified therapist's specialized judgement, knowledge and skills are necessary to perform safe and effective services in a maintenance program.
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 or caregivers.
See examples: Jimmo versus Sebelius Fact Sheet
Related Content
- CMS Internet-only-Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 Section 220.2 (D) Maintenance Therapy
- Local Coverage Determination L33631: Outpatient Physical and Occupational Therapy Services
- Local Coverage Article A56566: Billing and Coding: Outpatient Physical and Occupational Therapy Services
Revised 6/27/2023