MDS Alert

Published on Tue Feb 08, 2005 PDF

Question: Do Medicare rules ever allow you to delay skilled coverage for services beyond 30 days following a qualifying three-day hospital stay?

Answer: In limited cases, yes.

To do so, the facility must obtain documentation from the physician at the time of discharge from the hospital stating the resident will require within a certain timeframe daily skilled services that are a continuation of the services and/or treatment that the resident received during the hospitalization, says Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

If the resident enters the facility on the day of discharge from the hospital and cannot receive active rehab therapy/treatment (for example, due to his non-weight bearing status), the physician should write a note in the record indicating when the skilled therapy will be required, Mines advises. For example, the note might indicate the therapy will commence in five to six weeks. This resident can remain in the skilled facility on any payor source in a non-Medicare stay until he achieves weight-bearing status in the designated time period, Mines adds.

"Use a condition code of 56 on the UB-92 to prevent the claim from being edited out of the system. The letter or information from the physician indicating the medical appropriateness and predictability of the skilled rehab services must be on file in the nursing facility," Mines says.

The exception to the 30-day transfer period "applies only when part of the care required involves deferred care, which was medically predictable at the time of hospital discharge," states the Medicare Benefit Policy Manual (chapter 8). "If the deferred care is not medically predictable at the time of hospital discharge, then coverage may not be extended to include SNF care following an interval of more than 30 days of noncovered care."

Example: An individual is admitted to a SNF for daily skilled rehabilitative care. After three weeks, the physician discontinues the therapy because the patient's condition has stabilized and he no longer requires daily skilled services. Six weeks later, however, the patient requires daily skilled services again due to an unexpected change in his condition.

The second period of treatment wasn't predictable at the time of hospital discharge, so it doesn't qualify as care deferred until medically appropriate. Medicare would not pay in this situation.

To review the above example and additional ones related to the medical appropriateness exception, see the Medicare Benefit Policy Manual, chapter 8, pp. 13 and 14 at www.cms.hhs.gov/manuals/102_policy/bp102c08.pdf.