Your patient would be most appropriate for a:
Medicare B Maintenance Plan of Care
To recap, For Medicare to cover maintenance therapy, the following criteria must be met:
Medically Indicated:
Therapy is necessary to prevent or delay deterioration of functional status due to a qualifying condition.
The patient’s condition must be unstable, progressive, or complicated enough to require the skills of a clinician to provide safe and effective treatment
Reasonable and Necessary:
The therapy must be appropriate for the patient’s condition and not excessive.
There should be a reasonable expectation of maintaining the patient’s functional ability.
The treatment should align with accepted standards of practice.
Requires the Skills of a Clinician:
As with restorative therapy, maintenance therapy must require the skills of a licensed therapist.
The services must be necessary to prevent deterioration that could not be avoided without skilled care, due to the need for monitoring and frequent reassessment, or given the need for skilled facilitation or cuing for safe and effective performance of the exercise program.
Question: How often should I see my patient?
Maintenance Plan of Cares may require more frequent or less frequent visits depending on the individual patient’s needs. To determine your visit frequency, consider these factors:
Is your patient is capable of performing their maintenance program on their own, or with support from non-skilled caregivers or family members? If so, schedule your visits less frequently (ie. every 60 or 90 days) and focus on reassessment of function to determine efficacy of your current maintenance program and any necessary modification.
Is the maintenance program, or the patient, complex enough to require the skills of a clinician to implement the interventions? If so, schedule your visits more frequently (ie. every week or every other week) and focus on implementing the maintenance program during these visits, reassessing and modifying as needed or at CMS-required intervals.
Certification Requirements
Please be aware that any patient on a Medicare B Restorative Plan of Care MUST be under the care of either a Physician (Doctor of medicine or osteopathy) or a Non-Physician Practitioner (nurse practitioner, clinical nurse specialist, or physician assistants) who is willing to either provide a referral or sign the Initial Plan of Care and any future revisions to the plan of care that require recertification.
Changes for 2025: The CMS 2025 Medicare Physician Fee Schedule final rule introduced significant changes for physical therapy, particularly related to the plans of care requirement. For the plan of care, CMS has removed the requirement for physical therapists to obtain a referring physician's signature within 30 days of initiating care IF A REFERRAL FOR THERAPY INITIATED THE PLAN OF CARE. In these scenarios, therapists need to submit the plan of care to the referring physician within 30 days, but do not need this plan of care signed and certified. NOTE: If treat in a Direct Access state, and you are seeing your patient WITHOUT a referral on file, you are still required to have your Initial Plan of Care signed and returned within 30 days.
For more information related to Medicare B Plan of Care Certification, refer to the Medicare Policy Manual Chapter 15, Section 220.1.3, Certification and Recertification of Need for Treatment and Therapy Plans of Care.
Clinical Reassessments:
With a patient on a Medicare B Maintenance Plan of Care, you are required to complete a reassessment at the following points in care:
At or before every 10th visit.
If, and when, there is a change in clinical status requiring reassessment and revision of the patient’s treatment goals and interventions.
If you require additional visits beyond what was initially certified in the Initial Plan of Care.
When you complete your reassessment, you need to consider the same questions you did during your Initial Evaluation to determine whether they qualify for continued skilled care AND if should remain on a Maintenance Plan of Care OR transition back to Restorative Plan of Care. Choose the Back button below to go back to the starting page.