Question: I work in a SNF and there are times when we have patients admitted following an ORIF for a hip fracture. Most of the time these patients have non-weight bearing restrictions and usually after a few of weeks of therapy they are able to transfer safely with assistance but are unable to maintain the NWB status because they are either obese or dementia. Once they are at this level we are unable to keep them on skilled therapy while they are waiting for some level of weight-bearing. I have been told that if we discharge them to a long-term bed, can we pick them up when they are allowed weight-bearing and can use Part A. Is this true?
Answer: In the situation you describe, the patient can resume treatment under their Part A benefit and under the same "episode of care" if they can resume therapy within 30 days from discharge from their Part A stay. This is known as the 30 day transfer rule and can be found on the CMS website under the Medicare Benefit Coverage IOM (internet only manual) in§20.2 - Thirty-Day Transfer. If the patient has any skilled nursing needs, say for example, their incision still need daily care, then nursing can continue them under the Part a benefit.
There is also another option, but only if the patient is unable to start therapy upon discharge from hospital and the physician has identified what is known as the "Medical Appropriateness Exception" and can be found in the manual in § 20.2.2. This exception requires the physician to identify prior to discharge from hospital that the patient will require skilled care. This is commonly referred to as a letter of predictability.
"An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a predeterminable time period.
The fact that a patient enters a SNF immediately upon discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable"
Section 126.96.36.199 - Medical Needs Are Predictable continues with "This exception to the 30-day requirement recognizes that for certain conditions, SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge. Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it is applicable only where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame. Accordingly, to qualify for this exception it must be medically predictable at the time of hospital discharge that a covered level of SNF care will be required within a predictable period of time for the treatment of a condition for which hospital care was received and the patient must begin receiving such care within that time frame."
Therefore under these circumstances, the physician must identify the timeframe that the patient would be able to receive that skilled level of therapy. The manual includes an example such as yours. "An example of the type of care for which this provision was designed is care for a person with a hip fracture. Under the established pattern of treatment of hip fractures it is known that skilled therapy services will be required subsequent to hospital care, and that they can normally begin within four to six weeks after hospital discharge, when weight bearing can be tolerated. Under the exception to the 30-day rule, the admission of a patient with a hip fracture to a SNF within 4 to 6 weeks after hospital discharge for skilled care, which as a practical matter can only be provided on an inpatient basis by a SNF, would be considered a timely admission."
Disclaimer: The answers provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.
Pauline M. Franko is owner of Encompass Consulting & Education, LLC based in Tamarac, FL; The company specializes in Medicare Seminars and Webcasts as well as Consulting and Compliance Training. To learn more visit their website at www.encompassmedicare.com You may contact the author through the Encompass website or by phone at 954-720-4087.