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Hi.
Just because a person falls into one of the "top" RUGS, he/she is not
automatically coverable. The "presumed coverage" criteria only applies through
the ARD the 5 day assessment.
Many medical conditions can "make" a RUG--such as quadriplegia, MS, CP,
hemiplegia, etc.
The question is whether or not the person received daily skilled
services--in the CC RUG, daily nursing skilled services. If the patient did not,
you should feel confident in your decision.
I am not a billing person(I am a MDS coordinator) but I have a
question. A resident was discharged from Medicare due to not progressing in
therapy. At time of discharge there were no other skilling factors to proceed
with medicare coverage. during the following 7 days of observation for this
resident's sighnificant change off medicare ( we always do a SC when
resident is discharged from medicare), he picked up enough
doctor orders ( he also has DX of DM with 7 days injections, not a
new dx) to place him into a clinically complex category..
Question: The family has requested a demand billing feeling that he should
have continued with medicare coverage after d/c of therapy
because they feel he declined because we stopped therapy. Does anyone
agree that he should have been readmitted to medicare or will Medicare
agree with our decision?
To admit you were wrong is to declare you are
wiser now than before.
--Unknown
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