This is from the Medicare Benefit Policy Manual, Chapter 8, Section 20.1 - Three-Day Prior Hospitalization
"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."
Also, since a 3-day qualifying hospital stay is required before the beneficiary can receive any Part A coverage, the presumption of coverage cannot apply without a 3-day qualifying hospital stay.
Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
Subj: Qualifying hospital stay
Date: 12/23/03 5:03:34 AM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
Resident admitted to the hospital by hospice r/t wife no longer able to cope. Resident has met the 3 day requirement however, medicare denied the hospital stay and none of the care provided meets the criteria for presumed coverage and resident will not receive any qualifying skilled care here. I say not qualified for SNF med A coverage. What do you guys think?
