----- Original Message -----
Sent: Friday, December 05, 2003 3:49
PM
Subject: Re: Medicare B vs. Medicare
A
Michelle, I think the following cites might help
you-Caralyn
10.4.1 - Starting a Benefit Period -
(Rev. 1, 09-11-02)
A benefit period begins with the first day (not
included in a previous benefit period) on which a patient is furnished
inpatient hospital or extended care services by a qualified provider in a
month for which the patient is entitled to hospital insurance
benefits.
A provider qualified to start a benefit period is
a hospital (including a psychiatric hospital) or SNF that meets all the
requirements of the definition of such an institution. A hospital which meets
all requirements in Chapter 5, �20 of this
manual is also a qualified hospital for purposes of beginning a benefit period
when it furnishes the patient covered inpatient emergency services. Thus,
generally, the benefit period begins when covered inpatient services are
initially furnished to an entitled individual. However, the noncovered
services furnished by a nonparticipating provider can begin a spell of illness
only if the provider is a qualified provider. A qualified provider is a
hospital (including a psychiatric hospital) or a SNF which meets all
requirements in the definition of such an institution even though it may not
be participating.. A qualified hospital in Canada or Mexico is also a
qualified provider for purposes of beginning a benefit period when it
furnishes covered inpatient hospital services. If a person is in a
nonqualified institution and is subsequently transferred to a qualified
hospital (general or psychiatric), his/her benefit period begins on admission
to the qualified hospital.
Admission to a qualified SNF or to the SNF level
of care in a swing bed hospital begins a benefit period even though payment
for the services cannot be made because the prior hospitalization or transfer
requirement has not been met. Inpatient care in a Religious Non-Medical Health
Care Institution (whether as hospital or extended care services) can begin or
prolong a benefit period.
10.4.4 - Definition of Inpatient for
Ending a Benefit Period - (Rev. 1, 09-11-02)
Generally, a beneficiary is an inpatient of a
hospital if the beneficiary is receiving inpatient services in the hospital
(i.e., not on an outpatient basis). The type of care actually received is not
relevant.
However, a different definition of inpatient
applies in determining the end of a benefit period for a beneficiary in a SNF.
A beneficiary is an inpatient in a SNF only if the beneficiary's care
in the SNF meets certain skilled level of care standards. (BOLDING
MINE) The beneficiary must need and receive a skilled level of
care while in the SNF. This means that in order to have been an inpatient
while in a SNF, the beneficiary must have required and received skilled
services on a daily basis which could, as a practical matter, only have been
provided in a SNF on an inpatient basis. If these provisions were not met
during the prior SNF stay, the beneficiary was not an inpatient of the SNF for
purposes of prolonging the benefit period.
Use the following presumptions for determining
whether the skilled level of care standards were met during a prior SNF
stay.
Presumption 1: A beneficiary's care in a SNF met
the skilled level of care standards if a Medicare SNF claim was paid for the
care, unless such payment was made under limitation on liability
rules.
Presumption 2: A beneficiary's care in a SNF met
the skilled level of care standards if a SNF claim was paid for the services
provided in the SNF under the special Medicare limitation on liability rules
pursuant to placement in a non-certified bed.
Presumption 3: A beneficiary's care in a SNF did
not meet the skilled level of care standards if a claim was paid for the
services provided in the SNF pursuant to the general Medicare limitation on
liability rules. (This presumption does not apply to placement in a
non-certified bed. For claims paid under these special provisions, see
Presumption 2.)
Presumption 4: A beneficiary's care in a Medicaid
nursing facility (NF) did not meet the skilled level of care standards if a
Medicaid claim for the services provided in the NF was denied on the grounds
that the services received were not at the NF level of care (even if paid
under applicable Medicaid administratively necessary days provisions which
result in payment for care not meeting the NF level of care
requirements).
Presumption 5: A beneficiary's care in a SNF met
the skilled level of care standards if a Medicare SNF claim for the services
provided in the SNF was denied on grounds other than that the services were
not at the skilled level of care.
Presumption 6: A beneficiary's care in a SNF did
not meet the skilled level of care standards if a Medicare claim for the
services provided in the SNF was denied on the grounds that the services were
not at the skilled level of care and no limitation of liability payment was
made.
Presumption 7: A beneficiary's care in a SNF did
not meet the skilled level of care standards if no Medicare or Medicaid claim
was submitted by the SNF.
Presumptions 1 through 4 cannot be rebutted.
Thus, prior Medicare and Medicaid claim determinations that necessarily
required a level of care determination for the time period under consideration
are binding for purposes of a later benefit period calculation. Presumptions 5
through 7 can be rebutted by the beneficiary showing that the level of care
needed or received is other than that which the presumption
dictates.
Presumption 6 can be rebutted because the
Medicare skilled level of care definition for coverage purposes is broader
than the skilled level of care definition used here for benefit period
determinations. Specifically, the requirement referred to in Chapter 4,
�40.2 regarding prior
hospital care related to the SNF care is included in the Medicare SNF coverage
requirements but is not included in the standard for benefit period
determinations. Therefore, Medicare payment could have been denied for a SNF
stay on level of care grounds (i.e., not even waiver payment was made) because
of noncompliance with that requirement, even though skilled level of care
requirements for benefit period determinations were in fact met by the SNF
stay. Consequently, when Medicare SNF payment is denied on level of care
grounds, the beneficiary must be given the opportunity to demonstrate that
he/she still needed and received a skilled level of care for purposes of
benefit period determinations.
NOTE: Effective October 1,
1990, the levels of care that were previously covered separately under the
Medicaid SNF and intermediate care facility (ICF) benefits are combined in a
single Medicaid nursing facility (NF) benefit. Thus, the Medicaid NF benefit
includes essentially the same type of skilled care covered by Medicare's SNF
benefit, but it includes less intensive care as well. This means that when a
person is found not to require at least a Medicaid NF level of care (as under
Presumption 4), it can be presumed that he or she also does not meet the
Medicare skilled level of care standards. However, since the NF benefit can
include care that is less intensive than Medicare SNF care, merely
establishing that a person does require NF level care does not necessarily
mean that he or she also meets the Medicare skilled level of care standards.
Determining whether an individual who requires NF level care also meets the
Medicare skilled level of care standards requires an actual examination of the
medical evidence and cannot be accomplished through the simple use of a
presumption. Therefore, the previous references to Medicaid claims have been
deleted from those presumptions which establish that an individual does meet
the Medicare standards.
Medicare no-payment bills submitted by a SNF
result in Medicare program payment determinations (i.e., denials). Therefore,
such no-payment bills trigger the appropriate presumptions. This also applies
in any State where the Medicaid program utilizes no-payment bills which lead
to Medicaid program payment determinations. If a SNF erroneously fails to
submit a Medicare claim (albeit a no-pay claim) when Medicare rules require
such submission, intermediaries request a SNF to submit one. Once the no-pay
bill is submitted and denied, the applicable presumption (other than
presumption 7) is triggered. If a patient is moving from a SNF level of care
to a non-SNF level of care in a facility certified to provide SNF care,
occurrence code 22 (date active care ended) is used to signify the beginning
of the no-pay period on the bill and trigger the appropriate presumptions.
Where the presumptions are rebuttable (i.e., 5
through 7), rebuttal showings are permitted at both intermediary determination
levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the
status of a prior SNF stay is made at the time that an inpatient claim is
submitted and/or at the reconsideration level). Intermediaries evaluate
rebuttal documentation even if the presumption being rebutted was triggered by
a Medicaid denial.
This special rule for determining whether a
beneficiary in a SNF is an inpatient for benefit period purposes is applicable
in all cases where a prior SNF stay affects benefit period status, not only
when a beneficiary is in exhausted or copay status and is seeking to renew a
benefit period. The rule has equal application where it results in the
beneficiary starting a new benefit period and paying a new deductible without
receiving an increase in the amount of Medicare benefits paid.
30 - Skilled Nursing Facility Level of Care -
General
(Rev. 1, 10-01-03)
A3-3132, SNF-214
Care in a SNF is covered if all of the following four factors are
met:
�The patient requires skilled nursing
services or skilled rehabilitation services, i.e., services that must be
performed by or under the supervision of professional or
technical personnel (see ��30.2 - 30.4); are ordered by a physician and
the services are rendered for a condition for which the patient received
inpatient
hospital services or for a condition that arose while receiving care in a
SNF for a condition for which he received inpatient hospital
services
�The patient requires these skilled
services on a daily basis (see �30.6); and
�As a practical matter, considering
economy and efficiency, the daily skilled services can be provided only on an
inpatient basis in a SNF. (See �30.7.)
�The services must be reasonable and
necessary for the treatment of a patient�s illness or injury, i.e., be
consistent with the nature and severity of the individual�s illness or injury,
the individual�s particular medical needs, and accepted standards of medical
practice. The services must also be reasonable in terms of duration and
quantity.
If any one of these four factors is not met, a stay in a SNF, even though
it might include the delivery of some skilled services, is not covered. For
example, payment for a SNF level of care could not be made if a patient needs
an intermittent rather than daily skilled service.
In reviewing SNF services to determine whether the level of care
requirements are met, the intermediary first considers whether a patient needs
skilled care. If a need for a
skilled service does not exist, then the "daily" and "practical matter"
requirements are not addressed.
Eligibility for SNF Medicare A coverage has not changed with the
inception of PPS. However, the skilled criteria and the medical review process
have changed slightly. For Medicare to render payment for skilled services
provided to a beneficiary during a SNF Part A stay, the facility must complete
an MDS.
EXAMPLE
Even though the irrigation of a suprapubic catheter may be a skilled
nursing service, daily irrigation may not be "reasonable and necessary" for
the treatment of a patient�s illness or injury.
----- Original Message -----
Sent: Friday, December 05, 2003 3:21
PM
Subject: Re: Medicare B vs. Medicare
A
Now I am really confused. I thought that
Part B therapy 3 times a week was not considered skilled. According to
the Q&A in "Briefings on Long Term Care Guidelines" Kitt Wakeley, a
consultant for Pinnacle Healthcare Group, states that Part B therapy would
qualify as skilled service and therefore the 60 day would have to start over
after Part B ended. She quotes the Skilled Nursing Facility Manual
(CMS pub 12, section 240) "A benefit period begins with the first day which
a patient is furnished inpatient hospital or extended care service by a
qualified provider....". According to Kitt "extended care services"
would include part B therapy. Now I know that "consultant's" make
mistakes but it would be nice if someone could clear this up, if able.
We all know how Medicare works and how we are not supposed to know what is
going on. Any clarification would be great.
Michelle
----- Original Message -----
Sent: Friday, December 05, 2003 8:50
AM
Subject: RE: Medicare B vs. Medicare
A
Not so. If she was receiving
part b but was not skilled therapy, then she will qualify for another
benefit period again. Just because a resident receives part b, it
must be at a skilled level per medicare a guidelines to keep a resident
from receiving a new medicare a benefit period.
Brenda W.
Chance, RN, RAC-C
MDS
Coordinator
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-----Original
Message-----
From: Corey
[mailto:[EMAIL PROTECTED]]
Sent: Thursday, December
04, 2003 6:29 PM
To:
[EMAIL PROTECTED]
Subject:
Re: Medicare B vs. Medicare A
Sorry, I misread the
initial. Since she was receiving skilled services in October, even
though paid for by Part B, she would need a 60 day period from the day
after her last day of therapy, before you could re-skill after a 3 day
hospital stay.
----- Original Message -----
Sent: Thursday, December 04, 2003
5:22 PM
Subject: Medicare B vs. Medicare
A
Hello, i just need someones
direction for me to understand it right..... and maybe needs
supporting documentation too.
..... Resident has Medicare
Part A from May 28-July 11...then in October 2003, Therapy pick her up
on Medicare B, due to decline.... then in Nov. 17, 2003,
she went to Hosp. until 11/25/03.... Does she
qualify for another 100 days on Medicare Part A? I thought she doesn't
due to the fact that she received Therapy in October 2003 and that
consi-
dered skilled (no matter what the
pay source is) and no 60 days gap (wellness
period).
Am I wrong with my interpretations
with the guidelines? Pls. help me to clarify this. thank you... Happy
Holidays...
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