Questions and answers from the American Association of Nurse Assessment Coordinators (AANAC).

Here we address the ongoing mysteries of hospital transfer:

Q: A resident was transferred to the hospital on the afternoon on the 20th and returned on the afternoon of the 23rd. Does that qualify her for Medicare skilled A coverage?

A: If the patient had 3 nights in an inpatient hospital bed (with none of them in an emergency room bed, an observation bed, or other non-inpatient bed), then the requirement for the 3-day stay was met. This has become a big issue with the Office of Inspector General (OIG) (see OIG Reports: Ineligible Medicare Payments on the AANAC homepage [www.aanac.org] under "Need to Know").

Q: I'm confused about how the benefit period works with readmissions to the hospital and the SNF. Please help.

A: If a resident is discharged from Medicare Part A and is picked up again for skilled services within 30 days of that discharge, no new 3-day stay is needed, and he continues to use the remainder of the days available in the benefit period. In the absence of a 60-day break in skilled services and a subsequent 3-day stay, a resident can be discharged and readmitted to skilled services within the same benefit period any number of times (within the parameters stated above), continuing to use the remainder of the benefit period that started with the 3-day qualifying stay until he exhausts the 100 days. All of the requirements stated above must be met, in addition to another requirement that the stay be related to the qualifying hospital stay, even though the qualifying stay might not immediately precede the readmission. In other words, even though the readmission does not have to be for the exact same condition for which the resident was admitted during the preceding SNF stay, the covered condition does have to be related to that hospital stay. As per Medicare SNF Manual (Pub 12), Section 240:

An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if60 days have not elapsed between discharge and readmission. The stay need not be for related physical or mental conditions.

For the necessary relationship of a SNF patient's condition to prior hospitalization, see [section] 212, which states in part:

   To be covered, the extended care services must be needed for
   a condition which was treated during the patient's qualifying
   hospital stay, or by a condition which arose while he was in the
   facility for treatment of a condition for which he was previously
   treated in the hospital. In addition, the qualifying hospital stay
   must have been medically necessary.

This information can be found at http://cms.hhs.gov/manuals/12_snf/sn201.asp.

If a resident is discharged from Medicare Part A and the facility wants to cover the resident again for skilled services after day 30, a new 3-day stay is required. However, in the absence of a 60-day break in skilled services, he would continue to use the remaining days in the benefit period. The resident does not earn a new 100-day benefit period until he has a 60-day break in skilled level of care and a subsequent 3-day qualifying hospital stay.

Here is the Code of Federal Regulations reference (remembering that when the Medicare regulation talks about "post-hospital SNF care," it means skilled level of care):

[section] 409.36 Effect of discharge from post-hospital SNF care. If a beneficiary is discharged from a facility after receiving post hospital SNF care, he or she is not entitled to additional services of this kind in the same benefit period unless--

(a) He or she is readmitted to the same or another facility within 30 calendar days following the day of discharge; or

(b) He or she is again hospitalized for at least 3 consecutive calendar days.

Q: A resident has a stage 2 ulcer with some yellow slough on it. The surveyor says that staging it as a 2 is incorrect, that it should be a 4. How can that be right? The manual says only that a wound with necrotic eschar should be staged as a 4--it doesn't say anything about slough.

A: Although the RAI User's Manual does not address staging for ulcers specifically with slough, as a standard of practice, slough is defined by the U.S. Department of Health and Human Services in its Clinical Practice Guideline "Treatment of Pressure Ulcers," from the Agency for Health Care Policy and Research (AHCPR), as "necrotic (dead) tissue in the process of separating from viable portions of the body." A wound with slough cannot be staged for the same reason that a wound with black necrosis cannot be staged: It isn't possible to visualize the bottom of the wound bed to see exactly how deep the wound is. For MDS purposes, however, since the wound is necrotic, it is staged as a 4.

Q: I have always understood that a resident cannot be on hospice and part A at the same time. Now I'm told that in format|on is incorrect. Please help!

A: Residents who are on a Medicare hospice program cannot be covered by SNF PPS for problems related to the terminal condition They can, however, be covered by SNF PPS for problems unrelated to the terminal condition. This is from page 49 of Medicare Learning Network Quick Reference guide at http://cms.hhs.gov/medlearn/SNFFRManual.pdf:

Medicare Beneficiaries Who Are In Hospice

Medicare beneficiaries enrolled in the hospice program who are admitted to the SNF for their terminal illness are not covered by inpatient Part A SNF benefit

* Do not follow the PPS assessment schedule

* No discharge claim is necessary

* Be alert tot beneficiaries who opt out of the hospice program and revert to traditional Medicare coverage

Medicare beneficiaries enrolled in hospice who are admitted to a SNF for a condition unrelated to their terminal illness are governed by PPS regulations.

* Follow the PPS assessment schedule

* Bill covered claims with valid HIPPS codes

* Condition Code 07 [indicating treatment of nonterminal condition hospice] must be present on the claim

With thanks to Rena R. Shephard, MHA, RN, FACDONA, AANAC chair and president, and president of RRS Healthcare Consulting Services, San Diego.