MDS Alert

Published on Mon Mar 21, 2005 PDF

Here's what you need to know.

Question: When can SNFs skill residents for primarily psychiatric or behaviorally focused nursing care? Would the resident have to have a three-day qualifying stay in a psychiatric hospital to qualify for coverage? 

Answer: Skilled observation and assessment may be required for patients whose primary condition and needs are psychiatric in nature or for patients who - in addition to their physical problems - have a secondary psychiatric diagnosis, states the Medicare Benefit Policy Manual.

"These patients may exhibit acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior," according to the manual. "However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs that are primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.) Therefore, these cases must be carefully documented."

The basics: To qualify for Part A SNF coverage for psych or behaviorally focused care, the resident has to require daily skilled nursing care for a condition treated during a three-day acute-care stay, says Rita Roedel, MS, RN, a consultant with BDO/Heritage Healthcare Group in Milwaukee. "That care could have been provided on a regular hospital floor where staff titrated psychiatric meds and did testing to differentiate behavioral changes due to delirium versus a psychotic mood disorder, for example," she says. Or the resident could have received care for psychiatric or behavioral issues in the psychiatric unit of an acute care hospital - or in a psychiatric hospital.

Beware: "The Medicare Benefit Policy Manual states that even if a patient has a three-day qualifying stay in a psychiatric hospital, it'd actually be unusual for the person to require a skilled level of care based on a psychiatric condition alone," cautions Rena Shephard, RN, FACDONA, MHA, principal of RRS Healthcare Consulting in San Diego. 

Yet a medical review transmittal (January 2002) provides an example of a claim review with services billed at BB2 for seven days.
 
"The five-day MDS assessment showed the resident displayed daily wandering, daily physically abusive behavior and resistance to care daily," Shephard says. "This example was billed for seven days. While there's no way a behavior-only problem will classify a resident into one of the upper 26 RUGs, the lower 18 RUGs under Medicare pay more than Medicaid in most states."