It Takes The Skill of a Ninja

Focus young Grasshopper

Ninjas!!  That’s right, I got help from ninjas for this article.  All the other rehab blogs can just “suck-it” (like Shawn and Gus ‘Pysch’ style suck-it) because none are cool enough to hang with ninjas.  A Witty PT works hard to bring you the absolute best strategies for surviving in the physical therapy, occupational therapy and rehab worlds.  Worlds full of conflict and sticky situations. Who better than a ninja to teach us the ways of navigating unscathed through the healthcare battles we are all facing?

The world of rehab could certainly use some ninjas!  Not just to fight our battles, but to infiltrate all levels of healthcare policy.  Where they work covertly as PTs, OTs, SLPs and more during the day to then sabotage the greed and bureaucracy of policy at night.  I may have just created the best rehab based comic plot line ever! (Totally calling public “dibs” on that). We will get to the ninja wisdom in just a bit.

Conquering Confusion 

A continual source of confusion and conflict in skilled care is that of rehabilitative versus maintenance care.  So much confusion and conflict I felt the need to involve the ninjas. This topic has been argued in the smallest clinic to even the highest courts; and despite questions being answered through law creating settlements there is still confusion.  So now you see why I am involving ninjas?

For this article, we are only going to cover maintenance care under Medicare policy.  Some private health plans allow maintenance, but we need to keep things clear and simple today.  As always, refer to each specific health plan if you have questions as to if maintenance care is available. A HUGE disclaimer here as well.  Medicare policy can and will change. This article is meant for general help and reference, but it is your responsibility to stay up-to-date to any language or policy changes and to implement them in your practice. Most of the details to the article came directly from Medicare policy manuals, specifically Chapter 15 – Covered Medical and Other Health Services, Section 220 

Rehabilitative Care

First thing, I need to cover what rehabilitative care is real quick.  This is what most of us think of when we think of skilled care. Skilled rehab care to focus on restoration or improvement of a patient’s function over a reasonable amount of time with usual and customary care. For those that really want it, here is the CMS definition from the link above:

Rehabilitative Therapy – addresses recovery or improvement in function; and when possible restoration to a previous level of health and well-being. Therefore, evaluation and other assessment documentation should describe objective measurements that show improvements in function, decrease in severity or other rationale for an optimistic outlook to justify continued treatment. Improvement should be shown through the use of objective measurements and instruments.  If expected potential is insignificant in relation to the extent and duration of therapy to achieve such, it is not reasonable and necessary. Rehabilitative care:

  • Requires the skill of a therapist to safely and effectively furnish care
  • Requires the supervision of a therapist in completing the care if provided by assistants
  • Cannot be done by non-skilled personnel
  • Is not required for improvement following a transient and easily reversible reduction in function (brief bed rest, hospital stay, etc) that could be expected to improve as the patient gradually resumes normal activity.

Maintenance Programs

Now for maintenance programs.  This is skilled care provided to establish a program that will help a patient maximize or maintain progress they gained during therapy.  It may also be to help prevent or slow further decline of a patient due to their problems. I certainly cannot do justice to the actual language in the Medicare policy, here is the “lite” version:

Definition: Maintenance program means a program established by a therapist that consists of activities and or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to disease or illness.

Maintenance Program – The goals of a maintenance program would be to maintain functional status or to prevent further deterioration in function:

  • Establishment or design of maintenance programs – create the program and train non-skilled persons to carry it out.  May require periodic reevaluations to maintain the program.
  • Delivery of maintenance programs – turns on the need for skilled care.  A maintenance program can be generally carried out alone or with caregivers.  There may be some circumstances where skilled care is needed due to safety or to maintain the patient’s function or to prevent further decline.  This would generally be due to a circumstance of such complexity and sophistication that the skills of a therapist are required.

One other huge thing to note.  In Chapter 15, when it defines scope of what assistants can do PLEASE notice on pages 201 and 206 that physical therapy assistants (PTA) and occupational therapy assistants (COTA) cannot participate in providing care that would be considered part of the maintenance program. 

Services. The services of PTAs used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising physical therapist. PTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. (Page 201, Chapter 15, Section 230.1,C Medicare Benefit Policy Manual, revision 259 7/2019)

Services. The services of OTAs used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising occupational therapist. OTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service. They act at the direction and under the supervision of the treating occupational therapist and in accordance with state laws. (Page 206, Chapter 15, Section 230.2,C Medicare Benefit Policy Manual, revision 259 7/2019)

Daniel-san, Trust quality of what you know, not quantity…

Like many out there, I used to think between the two of these definitions I could see a Medicare beneficiary for just about FOR-EV-ER.  I quickly learned this thinking was wrong, and rightly so. Not just as a witty PT, but also as a Medicare tax paying American I had my concerns.  I knew there would be providers that would try to stretch these definitions with their patients. Clinics that would abuse the system and over-utilize, driving costs ever higher.  Sadly, there are some that do think this way and do practice this way. Not you though right! Remember, I have ninjas on my side. They can find you! [yeah, this is where you recite the Liam Neeson line from Taken in your head].  

Despite the confusion, the need for rehab services has been simplified for us by the use of three very important words.  SKILLED. REASONABLE. NECESSARY. In either scenario, the care provided has to be skilled, reasonable and necessary.  I won’t go into detail, you can get more detail about medical need here.  Sadly, there are many providers that forget those three words.  I see the documents every day. Many of you have worked in clinics or heard of clinics that don’t care about those 3 words either.  I will highlight a few things Medicare points out that we all need reminding of:

To be covered, services must:

  • Be skilled as described by CMS
    • A service is NOT considered skilled merely because it is provided by a therapist or assistant
    • Cannot be self-administered or safely provided by a trained, unskilled person
    • The unavailability of a competent person to provide non-skilled care does not make it a skilled service
  • Provided by qualified personnel
  • Be reasonable and necessary (refer to Medicare Policy Chapter 15, section 230)
    • Considered as an accepted standard of medical practice to be specific and effective for the condition being treated
    • The services are of a level of complexity that they need to be completed by a therapist or under supervision of one
    • The patient’s condition is such that the services required can only be safely and effectively performed by a therapist or assistant under supervision.
    • Cannot be determined solely based on diagnosis or prognosis
    • The amount, frequency and duration of the services must be reasonable under accepted standards of practice
  • NOT be for the general good and welfare of patients, caregivers or clinics and providers.

I’m gonna break this down:

Rehabilitative Care Maintenance Care Skilled or Unskilled
Restoring function and abilityMaintaining ability or preventing lossSKILLED
Use of objective measures to show regular progress with proper documentationEstablishing and teaching a plan with proper documentationSKILLED
Treatments and HEP according to clinical guidelines and researchTreatments and HEP according to guidelines and researchSKILLED
Treatment can ONLY be by qualified professionalsTreatment and training can ONLY be by qualified professionalsSKILLED

Enough from me for now?  

Are you ready for the Ninjas?  

Are you worthy of the Ninjas?

The Ninjas

They live and work among us.  They love and care for their patients.  They fight for justice in the dark corners of documentation and proof of skilled care.  They are Nicole Trubin, MS, OTR/L and Stephanie Mayer, DPT; The Note Ninjas!  I am so pleased to have their expertise in this article. If you are not aware of these ninjas you must check them out!  (Instagram handle @thenoteninjas) They give awesome real life examples of defensible documentation and how to show the skill used in doing so.  You thought Splinter was cool? Lets see him write Medicare compliant documentation proving skilled care of a 75 year old patient 18 months post stroke with continued hemiparesis.  Skilled care documentation takes cunning, skill, innovation, strength and courage. All the skills of a ninja.

Here is how Stephanie and Nicole break it down:

We work with two different therapy approaches: rehabilitative and maintenance.  When we initially evaluate our patients, we typically use a rehabilitative approach because they come to us with a new loss of function that we are trying to restore.  In some cases, our patients stop making progress but still benefit from PT or OT services. Thanks to the Jimmo vs Sebelius Ruling, January 24, 2013, we are allowed to continue to treat a patient despite having decreased potential to improve as long as we can show our unique skill. Maintenance therapy requires the skill of a clinician with the goal to prevent, or slow, further deterioration of a patient.

I can just see them sitting cross-legged on a pillow, in a meditative pose, eyes closed reciting this rehabilitative wisdom.  Short and to the point, yet deep and meaningful.

They continue [keep picturing two female ninjas seated in deep thought, passing along wisdom to those that seek it]…

Let us now recite a parable: There was a man named Frank in the 83rd year of life.  He presented to skilled PT after many falls. He struggled with the effects of Parkinson’s disease.  Initially, we may treat Frank following a rehabilitative approach thrice weekly (3 times a week to those that don’t speak ninja like me) to address deficits of strength, balance and continued falls. We may see minimal progress being made in therapy due to severe fluctuations in motor planning, ability to sequence, and fatigue.  Some days Frank may ambulate independently to the dining room and is able to follow 2-step commands for therapeutic exercises. However, when Frank is fatigued, he may require moderate verbal and physical assistance to complete balance exercises and therapeutic activities. Due to the progression of his condition Parkinson’s disease, if progress slows, we may convert the approach to maintenance care.

Maintenance therapy will provide Frank with continued skilled PT that neither him or his caregiver could perform.  We have provided his caregiver with HEP including postural correction, B/L LE strengthening and ROM exercises which the caregiver is now able to perform independently.  However, the caregiver lacks skills appropriate to adapt exercises based on Franks inconsistencies with fatigue and changing motor patterns. Therefore, Frank will require continued skilled PT services for improved quality of life.  We alter the visit frequency to 1x/week and then 1-2x/month on a maintenance program as appropriate. In this case, our documentation is the key to showing skilled therapy is medically necessary for reimbursement.

I can’t thank the The Note Ninjas, Nicole and Stephanie, enough for this example.  It perfectly illustrates starting care with rehabilitative skilled care and then moving to maintenance as Frank no longer made significant progress, but still needed help.  Another important thing they mention is the adjusting of the plan of care over time. As the caregivers become more able to help or Frank becomes more stable, less care is needed to maintain his condition. Again, I highly recommend seeking out these ninjas and learning their ways!

In fact, they have some awesome resources that give you all kinds of treatment ideas, recommendations for upgrading and progression, proper documentation education, and more for both general ADLS and Balance in the geriatric population.  I highly recommend you look into accessing both these guides. 



(These are affiliate links. makes a small commission when you buy from the link above.  However, we only endorse high quality and very useful products and people)

The Settlement

One last bit to cover in this article.  Stephanie and Nicole introduced it in their sage advice.  That is the Jimmo Vs Sebelius settlement agreement. Without going off on a big tangent, it became necessary to involve the courts in getting Medicare members the skilled care they needed.  You can certainly look up the history behind it.  The simple version is that coverage of care in skilled nursing, home health and outpatient therapy services does not fall on the presence of regular improvement.  Care for Medicare beneficiaries cannot be denied due to lack of progress only. What did not change is that services must be skilled in nature, reasonable and necessary. So in other words, care can be denied if it does not appear skilled in nature.  If it can reasonably be done by the patient or caregivers, it can be denied (no matter if a skilled provider gave the care or not) This is why the ninjas provide skilled care and the documentation of such. Catching on now?

As I mentioned before, the rehab world needs more ninjas.  We need providers that prove the worth of the treatment they provide.  We need providers that give skill with each patient encounter. Providers that give appropriate time between visits so a patient needs skilled care when they are seen again.  These types of providers are rehab ninjas.

Huge thanks for reading the article, an even bigger thanks for checking out The Note Ninjas.  The last thing I need is two ninjas on my bad side. I have included a few other examples supplied by Medicare, they can be accessed at the link above for section 220.  As always, if you have any questions please reach out.

Appendix – Medicare Examples

Example 1 – pt with PD is nearing OPPT discharge and requires help during the last weeks of treatment to determine what type of exercises will contribute the most to maintain function or slow deterioration.  Care is used to establish a maintenance program and then train family members. Care is then halted for a time until re-assessment may be needed

Example 2 – A person with MS is in need of a program to slow deterioration in daily tasks.  Therapy services from a PT are used to evaluate current ability and establish a maintenance plan. The patient is trained.  Any caregivers are also trained. The patient is discharged from care at that time and the provider does actually care out the program in clinic as this would be seen as non-skilled.

Example 3 – A new patient comes with a referral for PT due to an unhealed, unstable fracture.  The patient requires regular exercise to maintain function until further healing. The skill of a therapist are needed to insure the extremity is maintain in proper position during exercise, due to safety concerns, this could be seen as skilled care for a time.

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