Rena
Subj: Medicare PPS benefits
Date: 11/14/03 7:53:05 AM Pacific Standard Time
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I believe that this is something that has been discussed in the past, but as usual you donât think you need it until itâs too late so here it goesâ.
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 âpsychiatric or dementiaâ issues
-do they not still have to meet the criteria for appropriate RUG level either at the hospital or skilled services by us?
The issue addressed in this question apparently is the presumption of coverage, and is a misstatement of the regulation. The following is from the Medicare Benefit Policy Manual, which can be found at http://cms.hhs.gov/manuals/102_policy/bp102c08.pdf:
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Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance
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.)
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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
The same Chapter 8 of the Medicare Benefits Policy Manual addresses this question also:
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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 ânoncovered careâ 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 ÂÂ30) (Section 20.1)
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Skilled observation and assessment may also be required for patients whose primary condition and needs are psychiatric in nature or for patients who, in addition to their physical problems, have a secondary psychiatric diagnosis. These patients may exhibit acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior. However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs that are primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.) Therefore, these cases must be carefully documented (Section 30.2.3.2)
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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
Is there a detailed reference that I can refer to? ( I apologize in advance, I havenât pulled out the SNF PPS manual because people âin the knowâ that are well versed on this issue, have had variations in opinion, so I presume itâs not well spelled out there either!)
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Healthcare Consultant
