The Medicare Benefit Policy manual has been revised to clarify that skilled care and skilled therapy may be covered by Medicare even for conditions that will not improve. The revision was brought upon by the high profile Jimmo v. Sebelius case, where Jimmo plaintiffs contended that Medicare was unjustly denying claims based on an “improvement standard” which would allow beneficiaries to only receive coverage for skilled care that would improve their conditions.
Section 20.1.2-Determination of Coverage has been revised to state, “Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care.”
The manual revisions explain that skilled care may be needed to maintain a current condition or prevent or slow a patient’s deterioration. The revision also includes that providers must prove that skilled care was needed, as opposed to non-skilled care. In order to substantiate their claims, providers must include appropriate documentation.
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