Re: Deferred Medicare Coverage

[RRS2000]

The medical appropriateness exception is very specific to conditions for which the treatment delay is the established standard of practice in general as opposed to a decision that is made on a case-by-case basis.  The requirements are very specific, and the orders must be written at the time of discharge from the hospital.  The following is from section 20.2.2.1 of the Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance.  It can be found at http://cms.hhs.gov/manuals/102_policy/bp102c08.pdf

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This exception to the 30-day requirement recognizes that for certain conditions, SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge. Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it is applicable only where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame (underlining added).
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In the type of situation described above, it is acceptable to provide skilled nursing care or transfer training as appropriate to the resident on admission to the SNF, issue a denial when that coverage ends, and start therapy after the planned delay.  For details and examples, please see the publication cited above.

Rena

Subj: Deferred Medicare Coverage
Date: 11/17/03 8:40:28 PM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet



I've read thoroughly the 212.3 section of the SNF Manual regarding
Medical Appropriateness Exception for a Med A beneficiary who is not
going to be able to participate in therapy for more than 30 days due to
non weightbearing status of more than 30 days but I'm still confused.
Is the physician's statement on the discharge summary all that is
needed to take advantage of this, i.e., "I anticipate it will take 8 to
12 weeks for this fracture to heal and she will be nonweightbearing in
that time period" or does he need to say something more specific in
regard to Medicare?  And is is all right to use a week or two of Med A
for surgical incision care and therapy to train staff in transfers and
set up restorative nursing for exercises and then give a Medicare Denial
until the time therapy can resume?  How about the doctor who orders PT
for transfers and progressive strengthening with a nonweightbearing
order who doesn't mention how long the NWB is expected to last?  Can we
still get an estimate of time from him after the patient is admitted?
Thanks,
Sally

Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Healthcare Consultant