Here is the updated regulation from the current online manual at http://www.cms.hhs.gov/manuals/101_general/ge101c03.asp#10.4.3. It says essentially the same thing.
Medicare General Information, Eligibility, and Entitlement
Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations
<<
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.
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. 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.
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The part that intrigues me is the last part (in caps, for emphasis) of this paragraph:
"A resident will never have another benefit period as long as they
continue to receive skilled care after the benefits are exhausted and
the resident remains IN A CERTIFIED BED" without a break in skilled care."
This is a new twist. The last paragraph of the quoted material above talks about the beneficiary, after benefits are exhausted, receiving a skilled level of care in a SNF (Medicare-certified facility), not in a certified bed. I will be seeking further clarification of this.
Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
Subj: RENEWING BENEFIT PERIOD
Date: 1/2/04 2:36:11 PM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
I cannot believe it, however, I did receive this reply from CMS. I thought it might be useful to the billers and RNAC's on the list
Very interested in Rena and Theresa's comments
Delores
Subj: Re: Medical Devices and Prosthetics
Date: 1/2/2004 5:52:59 AM Pacific Standard Time
From: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet (Details)
FAH-11
Dear Ms. Galia:
Thank you for your email inquiry concerning a Medicare billing for a
resident in a certified SNF.
A UB-92 form should be submitted even if a Medicare beneficiary has
exhausted their Medicare Part A benefits.
When documenting the final UB-92 form, code 22 should be used
indicating that benefits have been exhausted and the date of the last
covered day on the UB-92 form or the electronic equivalent.
The CWF will not show a new benefit period for this resident 60 days
after the benefit period has been exhausted.
A resident will never have another benefit period as long as they
continue to receive skilled care after the benefits are exhausted and
the resident remains in a certified bed without a break in skilled care.
You may wish to reference Chapter V of the Skilled Nursing Facility
Manual for guidance for proper billing procedures at
www.cms.hhs.gov/manuals/.
Should you require additional assistance regarding this same matter,
please include the following reference number: 153990.
>>>CAGInquiries 12/01/03 04:27PM >>>
Dear Ms. Galias:
Thank you for your email inquiry. We are forwarding your inquiry to
our Center for Medicare Management. Currently they have a backlog of
inquiries, but will respond to you as quickly as they can.
>>><[EMAIL PROTECTED]> 11/29/03 05:32PM >>>
FirstName: DELORES
LastName: GALIAS
Email-address:[EMAIL PROTECTED]
Question: have spent hours searching the UGS and CMS website and
cannot come up with the documentation I need.
Example:
Resident is admitted to a certified bed in a SNF.
Had at least a 3-day qualifying acute care hospital stay
within 30 days of admission to the SNF.
Resident needed and SNF provided Total Enteral Nutrition
via Gastrostomy tube and met the Skilled guidelines of
amount of calories and fluid volume. [Feeding was
totally via g-tube, no oral]
Medicare Part A Benefits are exhausted, resident
continues to receive tube feeding at same level as when
receiving Part A benefits and remains in a certified
bed. Payment for the tube feeding is now billed to
Medicare Part B..
Questions:
1. Does the biller need to send in a UB when benefits
are exhausted?
2. How does the biller code the final UB, "no longer
skilled care" or
"continues to receive skilled care?" And What codes
are used for
each situation.
3. Will the CWF show a new benefit period for this
resident 60 days
after benefits have been exhausted?
4. Where can I find these instructions in print either
by UGS or CMS?
It is my understanding that the resident will never
have another benefit period as long as she/he continues
to receive skilled care after benefits are exhausted AND
the resident remains in a certified bed with no break in
skilled care and never leaving a certified bed.
Thank you in advance for your reply to this request.
Delores L. Galias, RN, RHIT
Address1:1981 RANGEVIEW DRIVE
Address2:
City:GLENDALE
State:CA
Zip:91201
Country:USA
