Re: Distinct part SNFs and end of benefit period

Thu, 27 Nov 2003 10:11:43 -0800

Cindy,
 
The topic of how a benefit period ends -- and the potential impact when certified/noncertified beds are involved -- was addressed by CMS in the October Skilled Nursing Facility/Long-term Care Open Door Forum. This forum is covered in the November issue of Postacute Payment Report. I have excerpted:
 
� How a benefit period ends.
    "Under the law, a benefit period ends after 60 consecutive days have elapsed where a person is not an inpatient of a hospital or of a SNF. On the SNF side, there are two different ways you can stop being an inpatient for benefit period purposes. One is if you physically leave the four walls of the building for 60 days. That ends your benefit period," say CMS officials. "But it is also possible to end a benefit period without actually leaving the SNF -- if the person drops below a covered skilled level for 60 consecutive days. If that happens, their benefit period ends even though they are in the building the whole time," they add.
    If part of the facility is certified as a Medicare SNF and part isn�t, "it gets a little bit more complicated," say CMS officials. "In the Medicare-certified part, the 60 days have to elapse where the person either leaves the building or drops below a skilled level of care. In the noncertified part, it comes down to whether that part of the facility meets the basic definition of a SNF for benefit period purposes, and the law defines that as any facility that is primarily engaged in providing skilled care to its residents. If the noncertified part meets that definition -- and we have administrative criteria that look at a number of factors, including nurse-to-bed ratios -- then it works the same way as in a Medicare-certified SNF. But if it doesn�t meet that basic definition of being primarily skilled, then a stay in that unit doesn�t prolong the benefit period no matter what kind of care the person gets there."
 
 
Below is an excerpt from the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations, which I believe is the reference for this. I haven't looked up the specific criteria mentioned above, but I am sure you can find it using the search function at http://www.cms.gov/manuals/default.asp. Also, if you have additional questions, the monthly Open Door Forum is held specifically to give the industry an opportunity to interact with CMS staff. If they can't answer your questions, they usually follow up on the next phone call and/or or give you a CMS official's e-mail address to follow up with you directly. It's a toll-free phone call and lasts about an hour. You can register for the SNF/LTC Open Door Forums at http://cms.hhs.gov/opendoor/ You will get e-mail announcements announcing when each month's forum will be held. -- Caralyn, Editor, Postacute Payment Report
 
 
10.4.3.2 - SNF Stay and End of Benefit Period - (Rev. 1, 09-11-02)

Similarly, to end a benefit period, a beneficiary cannot have been an inpatient (see subsection 10.4.4) of a SNF for at least 60 consecutive days; where SNF is defined as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.
 
----- Original Message -----
Sent: Wednesday, November 26, 2003 9:16 PM
Subject: Re: Tubefeeders

Cheryl,
 
Getting back to your original question:
 
I attended a Medicare Billing seminar by Adminastar Federal (Intermediary for Indiana and others) on 08/12/2003.  During a slide presentation, of which I have a copy, the gentlement stated that " Break in spell occurs if:  1.  Facility-free for 60 days or in noncertified bed (billed as non-resident) 2.  Non-skilled level of care for 60 days.".  Most of the room went WHAT????  This statement obviously has HUGE implications for those Nursing Facilities that maintain a distinct part as Medicare certified and do not have all their beds dually certified.  I did make a request for more official documentation and clarification but, of course, have never received anything. 
 
According to the above, anyone who was a tube feed and was moved out of the distinct part into a non certified bed would start a new benefit period after 60 days in that noncertified bed and could then again, presumably, be skilled for another 100 days for the tube or any other diagnosis following another qualifying hospital stay. 
Cindy Gilmer

C Hannant <[EMAIL PROTECTED]> wrote:
In agreement w/Denise, understand that I know everything everyone is telling me.  That is not the question.  There was supposed to have been a change to Tube Feeders not being skilled that was published in one of the monthly newsletters sometime around August.  Actually in a CMS Newsletter.  Now we know that they have been making changes and not getting the word out well, ie August changes that were only found by one of our members, also the new ABN form that's to start either this fall or next spring (who knows for sure).  That's all I'm asking for is the source document.

thanks...cher

[EMAIL PROTECTED] wrote:
Just a question, so please don't bite my head off >GRIN< As if this bunch would.
Thank you in advance for your replies?
 
If you have a resident on Medicare Part A with a Stage IV decub that you can't seem to heal and they used their entire 100 day benefit period. Would you put them back on Medicare Part A if after 70 days from being discharged from Medicare Part A the doctor put the resident in the hospital to repair the same Stage IV decub with a flap and kept them in the hospital for at least 3 midnight's?
Would this be the same as the resident being fed via the tube?
 
ask Sherry Kennedy to show you where the SNF manual was changed, regarding ending a benefit period. 
I agree with Holly on this one. In ALL my training from the FI, once a resident reaches a skilled level and stays at a skilled level exhausting all Part A benefits, there are no more Part A days. Part B may be different, but Not Part A.

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