Re: Medicare PPS benefits

[Caralyn Davis]

References that may be helpful to you:   1. From the new Medicare Benefits Policy Manual on the CMS web site:   30.1 � Administrative Presumption (Rev. 1, 10-01-03)     Under SNF PPS, beneficiaries who are admitted (or readmitted) directly to an SNF after a qualifying hospital stay are considered to meet the level of care requirements of 42 CFR 409.31 up to and including the assessment reference date for the 5-day assessment prescribed in 42 CFR 413.343(b), when assigned to one of the Resource Utilization Groups (RUGs) that is designated (in the annual publication of Federal prospective payment rates described in 42 CFR 413.345) as representing the required level of care. For purposes of this presumption, the assessment reference date is defined in accordance with 42 CFR 413.34(b), and must occur no later than the eighth day of posthospital SNF care. The coverage that arises from this presumption remains in effect for as long thereafter as it continues to be supported by the facts of the beneficiary�s condition and SNF care needs. However, this administrative presumption does not apply to any of the subsequent assessments.     A beneficiary who groups into other than one of the Resource Utilization Groups designated as representing the required level of care on the 5-day assessment prescribed in 42 CFR 413.343(b) is not automatically classified as meeting or not meeting the SNF level of care definition. Instead, the beneficiary must receive an individual level of care determination using existing administrative criteria and procedures.     In general, CMS presumes that beneficiaries admitted to an SNF immediately after a hospital stay require a skilled level of care. Therefore, CMS has developed the presumption of coverage policy outlined here in this subsection. This presumption of coverage policy applies to the Medicare stay from the date of admission to the ARD of the 5-day MDS.     When a beneficiary is assigned correctly into one of the top 26 RUG categories, it is believed that care provided to the beneficiary meets the skilled level of care definition. Nonetheless, there must be supportive documentation in the clinical record addressing the needs of the beneficiary and the skilled services being rendered to the beneficiary by the facility staff.     When a beneficiary is assigned into one of the lower 18 categories, he or she is not automatically classified as meeting or not meeting the definition of skilled services. An individual level of care determination using the administrative criteria outlined below should occur. These criteria are also used in situations where an MDS is not available (e.g., demand bills, bills submitted at the default rate, etc.)     2. From the new Medicare Benefits Policy Manual on the CMS web site:   20.1 - Three-Day Prior Hospitalization (Rev. 1, 10-01-03) A3-3131.1, SNF-212.1     The hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or, effective July 1, 1973, became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law. The three consecutive calendar days requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.     To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, including services of an emergency hospital, or a condition, which arose while in the SNF, or for treatment of a condition for which the beneficiary was previously hospitalized. In addition, the qualifying hospital stay must have been medically necessary. Medical necessity will generally be presumed to exist. When the facts, which come to the intermediary in its normal claims review process indicate that the hospitalization may not have been medically necessary, it will fully develop the case, checking with the attending physician and the hospital, as appropriate. The intermediary will rule the stay unnecessary only when hospitalization for three days represents a substantial departure from normal medical practice.     The 3-day hospital stay need not be in a hospital with which the SNF has a transfer agreement. However, the hospital must be a participating general or psychiatric hospital or an institution, which meets at least the conditions of participation for an emergency services hospital. A nonparticipating psychiatric hospital need not meet the special requirements applicable to psychiatric hospitals. Stays in Religious Nonmedical Health Care Institutions (See Pub 100-1, Medicare General Information, Eligibility, and Entitlement, Chapter 5, �40, for definition of RNHCIs) are excluded for the purpose of satisfying the 3-day period of hospitalization.     NOTE: 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 SNFs. 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. (See ��30.)   3. From the Medicare Program Integrity Manual on the CMS web site:       "Rules of thumb" in the MR process are prohibited. Intermediaries must not make denial decisions solely on the reviewer�s general inferences about beneficiaries with similar diagnoses or on general data related to utilization. Any "rules of thumb" that would declare a claim not covered solely on the basis of elements, such as, lack of restoration potential, ability to walk a certain number of feet, or degree of stability is unacceptable without individual review of all pertinent facts to determine if coverage may be justified. Medical denial decisions must be based on a detailed and thorough analysis of the beneficiary�s total condition and individual need for care.   You can access all of the new on-line manuals at http://www.cms.gov/manuals/cmsindex.asp. -Caralyn       ----- Original Message ----- From: Connie L. Frank To: '[EMAIL PROTECTED]' Sent: Friday, November 14, 2003 10:50 AM Subject: Medicare PPS benefits I believe that this is something that has been discussed in the past, but as usual you don�t think you need it until it�s too late so here it goes�.   2 questions hopefully this makes sense and you are able to enlighten me further: 1)       a comment was made to me that all individuals have a right to at least 5 days Medicare coverage following a 3 day + hospitalization, including those hospitalized for �psychiatric or dementia� issues -do they not still have to meet the criteria for appropriate RUG level either at the hospital or skilled services by us?   2)       have any of you held individuals following a 3 day + hospitalization for agitated/ aggressive behavior r/t dementia or unstable psych requiring medication adjustment and if so, what criteria do you look for prior to picking up and what guidelines are you using that justify continued skilled services         Is there a detailed reference that I can refer to? ( I apologize in advance, I haven�t pulled out the SNF PPS manual because people �in the know� that are well versed on this issue, have had variations in opinion, so I presume it�s not well spelled out there either!)