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This may give you more information - from http://www.cms.hhs.gov/manuals/12_snf/sn230-4.asp#_1_8,
"240 COVERAGE OF SERVICES 08-82 Duration of Covered Extended Care Services Under Hospital Insurance B. Ending a Benefit Period.--The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor an inpatient of an SNF. To determine the 60-consecutive-day period, begin counting with the day on which the individual was discharged.
C. Prolonging a Benefit Period.--It is important to note that for purposes of continuing a benefit period the hospital or skilled nursing facility in which the stay occurs need not meet all the requirements that are necessary for starting a benefit period. ...
Similarly, inpatient services in a skilled nursing facility will prolong a beneficiary's benefit period if the facility (including one primarily for the care and treatment of mental disease or tuberculosis) meets at lest the requirement that it is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for injured, disabled, or sick persons."
If you then look at the definition of inpatient of a SNF for ending a benefit period (see attached) - it appears that if the patient receives a skilled level of care (like Part B rehab 5X/week) AND is in a Medicare certified bed, they have interrupted their wellness period and would not have satisfied the requirements to bill for a new Part A stay.
Lita D. Atkinson
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In a message dated 2/24/2004 11:08:55 AM Eastern Standard Time, [EMAIL PROTECTED] writes:
Others in my facility still do not agree with therapy 5x/week interrupting a wellness period.... actually they are not really agreeing with anything except MCR A usage interrupting a benefit period.... They do agree a tube feeder never becomes "unskilled" for a 60 day wellness period, but I am having a hard time with Stage IV ulcers, therapy 5x/week with 150 minutes, etc. being reasons the resident has been skilled... I am just learning this myself... we were just looking to see if MCR A had been used in the past 60 days. If any of you have time (I know how valuable time is for all of us), please read the response below that I received from out therapy company & let me know what you think. I really need help with this. Hey Jamie,
I have continued to research the question you have about interruption of wellness period with Med B therapy 5 times per week. I agree that it is technically correct to say that therapy 5 times per week constitutes skilled service, and it seems logical that this could interrupt a wellness period. However, I have not been able to find a single episode where provision of therapy under Med B, actually interfered with Med A coverage within 60 days. I have also searched the CMS website and found nothing which specifically addresses the interruption of wellness period due to provision of Med B therapy 5 times per week. That doesn't mean its not an issue, just that it is not addressed that specifically. I have however been able to find a couple of incidents at ------------, where a patient received Med B therapy 5 times per week, went out to the hospital and came back in, all within a 60 day period and received Med A 100 days without question. Again, that doesn't mean it won't ever be an issue, but to this point it hasn't been. I also came across several questionnaires that different facilities use to determine Medicare A eligibility, and not a single one ask the question if therapy had been provided 5 times per week in a SNF setting in the prior 60 days. Again, doesn't mean its not an issue, but I haven't found any facilities that are taking Med B therapy provision into account when determining Med A eligibility. Also in regards to the definition of skilled care, there is the statement about "the patient whose inpatient stay is based solely on the need for skilled rehab services would meet the daily basis requirement if they receive those services at least five days a week," and of course our Med B patients are not receiving inpatient care solely based on rehab need. I think you are being very proactive to avoid a potential problem which is why you are so good at what you do! I'm glad I've learned how knowledgeable you are with this stuff so I can use you as a resource. I just don't want to be quick to react to a potential problem, since we have no historical precedent or any documentation where CMS addresses the issue specifically. At least no documentation that I've been able to find. I believe that we should proceed as follows: 1. I can emphasize the need for individualizing Med B frequency with the therapists. Frequency decision should be based on clinical need and not everyone needs to automatically receive 5 times per week. By that same token, I wouldn't want to see all Med Bs suddenly go to 3 times per wk. This lower frequency would not be clinically appropriate for many of our swallowing, positioning or splint patients. 2. Let me know if there is a specific patient that you feel is at particular risk for hospitalization and need for wellness period. If a hospital admission and need for Med A benefit is highly probable, then we can jointly determine if its in the best interest of that patient and the facility to treat 3 times per week instead of 5, or even 4 times per week. 3. Most importantly, I will have the therapists do whatever my customer says! If the powers that be decide that we should aggressively move towards seeing our Med B patients 3 times per week, we will comply. 4. Finally, I will continue to search for more concrete answers and you do the same. I'm going to try to reach ________ today. She has always been a good resource for me. Keep me informed of anything you find out and I'll do the same. Thanks, |
Benefit period info.doc
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