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I think that the counting of a "utilization day"
(i.e., 100 SNF benefit days) may be different than PAYMENT days. According
to the SNF manual :
section 5l7.6 Determining Whether a Part of a Day
is a Utilization Day.--
A. Day of Admission.--The day of admission
counts as a utilization day except in the situation where the patient was
admitted with the expectation that he remain overnight but was transferred to
another participating provider before midnight of the same day. In this
instance, the first provider shows "l" in Item 24, Noncovered Days and "0" in
Item 23, Covered Days, and does not complete Item 60, Inpatient Deductible or
Item 61, Coinsurance, or make a deductible or coinsurance charge to the patient.
The provider to which the patient was transferred counts the admission day as a
utilization day and completes Items 60 and 61, includes the day in Item 23, and
makes a deductible or coinsurance charge to the patient where
applicable. Both
providers may bill for accommodation and ancillary
charges. [emphasis mine]
This
general rule applies to transfers between SNFs and between a hospital and an
SNF. However, under these same circumstances, if the two providers represent an
institution composed of a participating hospital and a distinct part
participating SNF, the first provider cannot bill for accommodations, but may
bill for ancillary charges.
This rule refers to a "participating provider" AND
indicates that both providers may bill. I find it hard to believe that the
"new" CMS manual would intend to change the rule.
----- Original Message -----
Sent: Sunday, January 11, 2004 12:35
PM
Subject: Re: ff-up question
According to the regulation, if the resident
was not discharged to another Medicare-participating provider, such as a
hospital or Medicare-certified nursing home, then even though it is the day of
discharge, the facility can bill for the day. In that case, the facility
has a choice of billing the default rate or completing the 5-day assessment
with as much information as is available and billing the resulting RUG
rate. In my experience, in general the payment difference between
the default rate and the RUG rate is well worth the minimal amount of dollars
in staff time it takes in this type of situation to complete the 5-day
assessment versus having a blanket policy to always accept the default rate in
this type of situation. It is my opinion that the administrator should
make this policy decision based on a cost/benefit analysis, since the
administrator is the one keeping an eye on the dollars.
If the resident
was discharged to a Medicare-participating provider, then the SNF cannot
bill the RUG rate or anything else for that day.
Here is the
regulation that covers the determination of whether the day can be billed as a
utilization day:
<<QUOTE
Medicare Claims Processing Manual
Chapter 6 - SNF Inpatient Part A Billing
40.3.5 - Determine
Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence
(Rev. 1, 10-01-03)
SNF-517.6.B, A3-3103.4
Generally, the day of
discharge, death, or a day on which a patient begins a leave of absence, is
not counted as a utilization day. (See the Medicare Benefit Policy Manual,
Chapter 3, "Duration of Covered Inpatient Services.") This is true even where
one of these events occurs on a patient's first day of entitlement or the
first day of a provider's participation in the Medicare program. In addition,
a benefit period may begin with a stay in a hospital or SNF, on that day.
The exception to the general rule of not charging a utilization day for
the day of discharge, death, or day beginning a leave of absence is where the
patient is admitted with the expectation that he will remain overnight but is
discharged, dies, or is transferred to a nonparticipating provider or a
nonparticipating distinct part of the same provider before midnight of the
same day. In these instances, such a day counts as a utilization day. This
exception includes the situation where the beneficiary was admitted (with the
expectation that he would remain overnight) on either the first day of his
entitlement or the provider's first day of participation, and on the same day
he was discharged, died, or transferred to a nonparticipating provider.
Payment is not made under PPS unless a covered day can be billed. Also, if
no-payment is possible under PPS, billing is not allowed for ancillary
services. Ancillary charges for these days have been included in the PPS rates
for days that can be billed.
>>ENDQUOTE
And this describes
the use of the default rate - from Medicare's Medlearn site at http://cms.hhs.gov/medlearn/SNFFRManual.pdf
"Reporting
the Assessment Reference Date
(ARD) on the Claim
â Each assessment must
have an ARD (if no
assessment was completed, bill the claim with
the
default code if covered care was provided)" (p. 36)
"Billing the
default code signifies that the SNF
considers the resident to be at a
skilled level of
care, but no assessment was completed to
classify
him/her into a RUG III group" (p. 45)
Rena
Rena R. Shephard,
MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment
Coordinators
[EMAIL PROTECTED]
Subj: ff-up question
Date: 1/10/04 7:43:10 PM Pacific
Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
Somebody sent a question regarding a medicare resident that
was admitted at 3:00 pm and was discharged at 10:00 pm the same date, and
the question was, does she need to do a 5 day asmnt although she was not
there over midnight?
I am interested to the answer too. Rena, if you are there, can you give
your input about this and we want to know the regulations too.
thanks.
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