Hi, Group,
Tell me how y'all handle "routine" stuff that comes up during a Med A
stay. (Such as eye care, other follow up visits that are unrelated to
the qualifying hosp stay.)
Right now, we have 2 medicare residents who had been scheduled for
cataract surgery prior to their acute illnesses which precipitated their hosp
stay and SNF admission. One of them had bowel obstruction which required
resection, complicated by peptic ulcers that bled, etc. She was in the
hospital for 3 weeks, followed by 19 days in TCU prior to admission at our
facility. The other was admitted for acute, severe CHF exacerbation, and
had a pretty severe psychotic episode during the hospital stay. They are
both receiving PT and OT and slowly improving.
Both have very challenging personalities and even more challenging
families to deal with.
Like I said, these ladies had been scheduled for cataract surgery before
all the acute stuff happened. The ophthalmologists postponed the surgeries
pending the resolution of the acute illnesses. Well, now, both of the
families are demanding that we schedule the office visits and cataract
surgeries. I have tried explaining the rationale of waiting until the
other processes have resolved, and that these procedures are not related to
the hospital stay, etc. Both families have interpreted my stance as
suggesting that the facility just doesn't want to pay for the procedures.
(well, okay, that's part of it) One of them said, "The money is
not an issue. We will pay for this. We want it done now."
My BOM looked up the HCPCS that we got from the ophth and says they are
not excluded.
So, what are we supposed to do? When I did vision RAP on both of
these, neither seemed to be significantly impaired in daily activities due to
their vision. One of them has already had one cataract done, and the vision in
that eye is almost perfect. The other one also has glaucoma, but was
able to read all sizes of newsprint (including the tiny little print on the
bylines) with her glasses on. If I felt that there was a patient care or
quality of life issue, I would be on the phone myself to make the
appointment. But, for both of these folks, it just seems like a
really poor use of our limited resources to pay for these procedures, just
because they are in their Med A stay.
Any ideas? Any regulations or sources I could use to back up my
position and not look like a big meanie?
Thanks!
Holly
