If you skill for observation only, the resident would not classify into one of the upper 26 RUG categories, and the presumption would not apply.
See the PPS Final Rule, July 30, 1999.
Also see Medicare Benefit Policy Manual:
Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance:
<<QUOTE
Under SNF PPS, beneficiaries who are admitted (or readmitted) directly to an SNF after a qualifying hospital stay are considered to meet the level of care requirements of 42 CFR 409.31 up to and including the assessment reference date for the 5-day assessment prescribed in 42 CFR 413.343(b), when assigned to one of the Resource Utilization Groups (RUGs) that is designated (in the annual publication of Federal prospective payment rates described in 42 CFR 413.345) as representing the required level of care. For purposes of this presumption, the assessment reference date is defined in accordance with 42 CFR 413.34(b), and must occur no later than the eighth day of posthospital SNF care. The coverage that arises from this presumption remains in effect for as long thereafter as it continues to be supported by the facts of the beneficiary's condition and SNF care needs. However, this administrative presumption does not apply to any of the subsequent assessments.
A beneficiary who groups into other than one of the Resource Utilization Groups designated as representing the required level of care on the 5-day assessment prescribed in 42 CFR 413.343(b) is not automatically classified as meeting or not meeting the SNF level of care definition. Instead, the beneficiary must receive an individual level of care determination using existing administrative criteria and procedures.
In general, CMS presumes that beneficiaries admitted to an SNF immediately after a hospital stay require a skilled level of care. Therefore, CMS has developed the presumption of coverage policy outlined here in this subsection. This presumption of coverage policy applies to the Medicare stay from the date of admission to the ARD of the 5-day MDS.
When a beneficiary is assigned correctly into one of the top 26 RUG categories, it is believed that care provided to the beneficiary meets the skilled level of care definition. Nonetheless, there must be supportive documentation in the clinical record addressing the needs of the beneficiary and the skilled services being rendered to the beneficiary by the facility staff.
When a beneficiary is assigned into one of the lower 18 categories, he or she is not automatically classified as meeting or not meeting the definition of skilled services. An individual level of care determination using the administrative criteria outlined below should occur. These criteria are also used in situations where an MDS is not available (e.g., demand bills, bills submitted at the default rate, etc.)
>>END QUOTE
Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
Subj: Re: RE: Medicare Eligible
Date: 3/10/04 9:57:59 PM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
I thought that when resident returned from hospital from 3 day hospital stay there was a "presumption of coverage" and that you had to have a pretty darned good reason for not admitting Medicare. If you skill for observation (after all she had to be in the hospital for something) then if you set ARD for day 5 Med A coverage would apply thru day 5. We were told at legal seminar that presumtion of coverage was really important -- that if person has Part A benefits that we (SNF) were generally not entitled to presume to take that benefit away. I'm paraphrasing, but I guess you get drift.
>
>From: "Angie Palac" <[EMAIL PROTECTED]>
>Date: 2004/03/03 Wed AM 06:54:30 EST
>To: <[EMAIL PROTECTED]>
>Subject: RE: Medicare Eligible
>
>Resident was treated for anemia and had a blood transfusion which would
>skill her for at least 5 days. MDS coordinator asked me if per chance
>the resident did not have anything to skill her in the hospital and she
>was not appropriate for therapy, how would the facility bill for the
>days she was in a Medicare bed until the evaluation was done and
>determined she was not Medicare eligible (admit Friday and eval on
>Monday). I don't know if this scenario ever happens. It seems to me
>that the report from the hospital would determine if she was eligible or
>not, and if not, do not put her in a Med A bed.
>
>Thanks, Angie
>
>-----Original Message-----
>From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of
>claudia farrell
>Sent: Wednesday, March 03, 2004 5:21 AM
>To: [EMAIL PROTECTED]
>Subject: RE: Medicare Eligible
>
>Did the patient have IV's in the hospital? what were they tx for first.
>claudia farrell rn
>
>
>
>Claudia
>>From: "Angie Palac"
>>Reply-To: [EMAIL PROTECTED]
>>To:
>>Subject: Medicare Eligible
>>Date: Tue, 2 Mar 2004 21:31:48 -0600
>>
>>If a resident is admitted to a Nursing Home after a 3 day hospital
>stay,
>>and therapy was ordered, but unfortunately the resident was not
>>appropriate for therapy, what does the facility do? For example, the
>>evaluation was not done until Monday because the resident was admitted
>>late Friday. How does the facility bill for Friday, Saturday and
>Sunday,
>>and lets presume that there is nothing that the facility can capture
>>from the hospital. Has this ever happened to anyone? Any help would
>be
>>much appreciated.
>>
>>Angie
>
>
