Part A coverage in a SNF following a stay in a psych hospital can be tricky. First, the Part A coverage must be needed for a condition which was treated during the patient's qualifying hospital stay, or by a condition which arose while he was in the SNF for treatment of a condition for which he was previously treated in the hospital. It is not clear whether your resident meets this condition.
Second, for any resident to be covered for rehab, the services must be complex enough that the skills of a rehab therapist are required. Here is what the Medicare SNF Manual says about gait training:
"(2) Gait Training.--Gait evaluation and training furnished a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality require the skills of a qualified physical therapist. However, if such gait evaluation and training cannot reasonable be expected to improve significantly the patient's ability to walk, such services would not be considered reasonable and necessary. Repetitious exercises to improve gait or maintain strength and endurance and assistive walking, such as provided in support for feeble or unstable patients are appropriately provided by supportive personnel, e.g., aides or nursing personnel, and do not require the skills of a qualified physical therapist." (Section 230.3)
And here is what the Medicare SNF Manual says about coverage following a psych stay:
"While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions which primarily provide psychiatric treatment cannot participate in the program as skilled nursing facilities. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only noncovered care. In the SNF, the term "noncovered care" refers to any level of care which is less intensive and skilled than the SNF level of care which is covered under the program." (Section 212.3)
Here is an example of coverage for behavior problems after an acute hospital stay. Note that this resident classified into one of the lower 18 RUGs, so there is no presumption of coverage and supporting documentation is the key to getting the claim paid. This is from Transmittal 18, January 2002, Medical Review of Skilled Nursing Facility Prospective Payment System (SNFPPS) Bills.
Services Billed: BB201 for days 1-7
Supporting Documentation:
MDS:
" 5 day assessment
" E4a Wandering + 3 (occurred daily) checked
" E4c Physically abusive behavioral symptoms = 3 (occurred daily) checked
" E4e Resists care = 3 (occurred daily) checked
Medical Record:
" The resident was in the acute care setting for greater than 3 days for a new onset of confusion and anxiety.
" Documentation clearly shows these behaviors on a daily basis in the seven-day look back period including the ARD and the behavior continued throughout the billing period.
" Documentation noted the need to switch the patient's medications being used to modify his behavior due to the sudden appearance of a rash over his entire body on the 4th day of his admission to the SNF.
Review Determination:
" This claim would be paid as billed.
HIPPS Codes Indicating Classification into the Lower 18 RUG-III Group
If you do pick up this resident on Part A now, day 1 of the PPS stay is the 1st day of Part A coverage.
Rena
Subj: Re: Rena......help please
Date: 10/31/03 10:57:24 AM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
What does the Physical Therapy have to do with the Geropsych stay? In order to cover her for Medicare , the coverage must be required to cover a condition that was treated during the acute stay or the skilled stay in your facility. Since you did not originally cover her, the condition must be related to something that was treated in the acute stay.
-----Original Message-----
From: [EMAIL PROTECTED]
Sent: Oct 31, 2003 9:48 AM
To: [EMAIL PROTECTED]
Subject: Rena......help please
Had resident return from gero psyche on 10-24-03. Was not readmitted on Part A Medicare. Today is 10-31-03 and P.T. wants to pick her up on Part A Medicare. Can we do this and do the PPS assessments start from day one or today's date. I just can't remember. Please.....need help ASAP
Thanks,
Susan Gibbs, RN
Presbyterian Homes
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators (AANAC)
"Setting the standard for SNF MDS/PPS education"
President, RRS Healthcare Consulting Services
17210 Russet Street
San Diego, CA 92127
858-592-6799
858-592-6800 (fax)
858-254-0851 (mobile)
[EMAIL PROTECTED]
www.AANAC.org
