Page 191 - Medicare Benefit Policy Manual

and would be covered. NOTE: In this example, the skills of a therapist are not required
to actually carry out the maintenance program services and, as a result, are not covered.

Example #3 describes a scenario where the skilled services of a therapist would be
necessary to actually carry out the maintenance program services.

EXAMPLE: Where there is an unhealed, unstable fracture that requires regular
exercise to maintain function until the fracture heals, the skills of a therapist may
be needed to ensure that the fractured extremity is maintained in proper position
and alignment during range of motion exercises. In this case, since the skills of a
therapist may be required to safely carry out the maintenance program given this
particular patient’s special medical complications, therapy services would be
covered.

Example #4 describes another scenario where the skilled services of a therapist are needed
to actually carry out the maintenance program services.

EXAMPLE: A patient with a long history of Multiple Sclerosis has difficulties
transferring in and out of the wheelchair and maintaining range of motion (ROM)
of the lower extremities (LEs) due to increased spasticity muscle tone since the
most recent exacerbation episode of her Multiple Sclerosis. The beneficiary is
unable to walk but is independent with the use of her wheelchair. The beneficiary
needs to be able to safely transfer in and out of her wheelchair by herself or with
the assistance of a family member or other caregiver(s). After an individualized
assessment by the physical therapist, and given the patient’s overall medical and
physical condition, the skills of the physical therapist are required to instruct the
patient and/or caregivers in proper techniques of wheelchair transfers and LE
stretches due to the special medical complications from the progression of
Multiple Sclerosis. When the physical therapist determines that the patient can
carry out the transfers and stretching activities safely and effectively, either alone
or with the assistance of the caregivers, the skills of the physical therapist are no
longer necessary to furnish the maintenance therapy; and, the patient is discharged
from PT.

Example #5 describes a scenario where a patient on a maintenance program needs
intermittent review and possibly a new or revised maintenance program.

EXAMPLE: A patient who has a progressive degenerative disease is performing
the activities in a maintenance program established by a therapist with the
assistance of family members. The program needs to be re-evaluated to
determine whether assistive equipment is needed and to establish a new or revised
maintenance program to maintain function or to prevent or slow further
deterioration. Intermittent re-evaluation of the maintenance program would
generally be covered as this is a service that requires the skills of a therapist.
Should the therapist conducting the re-evaluation determine that the program
needs to be revised, these services would generally be covered.