MDS Alert

Published on Tue Jan 04, 2011 PDF

Apply this key litmus test to see if residents qualify for dual coverage.

Pivotal: "The hospice benefit covers items and services related to the terminal illness and related conditions," says attorney Marie Berliner, in Austin, Texas. Thus, whether the hospice patient qualifies for Part A SNF services depends on whether his three-day qualifying hospital stay was related or not to his terminal illness or related conditions. (The person would, of course, have to have days left in his SNF benefit period and meet medical necessity requirements for SNF Part A services, etc.)

Example: Suppose a patient with a hospice diagnosis of colon cancer falls and breaks a hip, says hospice consultant Beth Carpenter in Lake Barrington, Ill. "The MAC/FI can say the chemotherapy weakened the person's bones, causing the hip to fracture and the person to fall," she cautions.

"Scenarios that would qualify for both Part A SNF care and hospice care would be a fall or other condition where the cause is outside the hospice diagnosis," says Carpenter. An example would be a hospice patient who falls due to a wet floor or obstacle on the floor, requiring hospital care followed by SNF services to treat the injury, she adds. "The same would be true of a medication error that caused an adverse drug reaction."

2 more potentially covered examples: Suppose a hospice recipient receiving an inpatient level of hospice care in the hospital developed a hospital-related MRSA infection that other patients developed in the same hospital unit. That type of scenario would "potentially qualify as a three-day stay for purposes of triggering SNF coverage under Part A," says Berliner.

Or suppose a person with cancer as the terminal diagnosis is injured in a car accident and receives surgery as a hospital inpatient, remaining in the hospital for three days, says Berliner. Then he needs to recuperate in the SNF. "The hospice patient would likely qualify for SNF coverage based on the hospital stay, which was unrelated to the terminal condition," says Berliner.

Key: "The attending or medical director for the hospice and the hospital admitting physician and the patient's SNF attending physician should be in agreement that the issues were unrelated," Berliner stresses. And the hospice, hospital, and SNF documentation should "clearly and separately" indicate that's the case.

Must-have: "If the beneficiary revokes his/her hospice benefit, the revocation must be in writing," says Berliner.