Questions and answers from the American Association of Nurse Assessment Coordinators (AANAC). (AANAC's PPS Review).

We lead off with two particularly common--and complicated--questions:

Q 1: A resident was discharged to the hospital as a result of urosepsis. When she left our facility, she had two stage II decubiti. She was put in the PPS category for skilled observation (s/p urosepsis, had IV in the hospital), and as of the fifth day she was stable. Can I continue to skill her for wound care even though the decubiti were not the reason for her hospitalization?

Q 2: If a tube feeder goes home from the SNF with his tube-feeding apparatus, returns to the hospital after 60 days for at least 3 days and then returns to the SNF, does he earn a new SNF benefit period?

A: We have received so many e-mails about these questions, with so many different interpretations resulting, that we were moved to consult with one of CMS's leading Medicare experts, Bill Ullman, technical adviser in the CMS Division of Institutional Postacute Care. He said the answer to both questions is "yes," as long as the services provided meet other applicable requirements to qualify as a skilled service.

Part of the confusion arises because some interpreters of the regulations conclude that the skilled service provided in the SNF must be related to the primary diagnoses addressed in the hospital. That is not the case. As long as the service meets the definition of "skilled" level of care and the other eligibility requirements and was provided in the hospital, then it would be coverable in the SNF.

Here is the relevant part of the regulation (from the Medicare SNF Manual [Pub 12]):

212.1 Three-Day Prior Hospitalization.--The hospital discharge must have occurred on or after the first day of the month in which the individual attains age 65 or becomes entitled to health insurance benefits under the disability or chronic renal disease provisions of the law. The 3 consecutive calendar days requirement can be met by stays totalling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.

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.

In addition, with regard to the tube-feeding question above, since the resident had a 60-day break in skilled services while at home, a new benefit period would begin upon readmission to the SNF.

An example of a situation in which services would not be considered to be skilled would be the patient receiving the same respiratory treatments for a chronic, stable condition while in the hospital that he had received at home. If that patient is admitted to the SNF after a 3-day stay, Ullman acknowledged that the respiratory treatments would not be a covered service, because only the initial phases of treatment involving medical gases are considered to be a skilled level of care. The resident would be covered if his respiratory status was unstable, i.e., he would be covered for observation and assessment, management of the care plan, etc.

More questions:

Q: A resident is admitted with a private insurance as primary payer and Medicare as secondary. On day 45, the facility is notified that the primary insurance covers only through day 30. How can we be paid for days 31 through 45 other than by billing at the default rate?

A: The Provider Reimbursement Manual (PRM)--Pub 15-2, Section 2836J--addresses this issue. The short answer is that you can use either the PPS assessment for the applicable period, if you have been following that schedule, or the most recent OBRA-required comprehensive assessment. Here, specifically, is what the PRM has to say about it: Medicare Secondary Payer (MSP). Medicare regulations require SNFs to follow admission practices which include a survey for coverage by another insurer. If another insurer is responsible for the payment of the SNF stay, the SNF will bill the insurer according to the rules of the insurer. When a specific time period is guaranteed by an insurer other than Medicare, the assessment schedule for purposes of Medicare coverage and payment begins when that coverage ends. When the time paid by another insurer is based on dollars available on the policy or medical limitations of the policy, it is recommended (but not required) that the SNF follow the Medicare required assessment schedule during the period of coverage by another insurer to insure correct billing to Medicare if the other insurer denies payment. If the SNF does not follow the Medicare required schedule, and payment is retroactively denied by the primary insurer, the SNF may use the most recent assessment that was completed in accordance with the schedule outlined in 42 CFR 483.20(b)(4)* in order to receive payment under the Medicare program for those days that were denied by the secondary insurer, as long as the beneficiary meets all applicable eligibility and coverage requirements. *The CFR citation above refers to comprehensive assessments and the OBRA assessment requirements.

Q: My consultant says that when you add up the minutes for rehab for the MDS, you need to round down to the number of minutes closest to the number of 15-minute units. There is no way to avoid this "glitch" due to the billing requirement for units that does not equally match the provided number of minutes. Is this correct?

A: No, it is not correct. The minutes that are entered on the MDS have no relationship to the units calculated on the UB-92. This is from the PPS Final Rule (July 30, 1999), p. 41661:

If the beneficiary received PT for 50 minutes on both the second and fifth days of the Part A covered stay, that would be recorded as two days of PT and 100 total minutes of PT. The actual number (not rounded) of minutes must be recorded on the MDS. Minutes cannot be rounded to multiples of 10 or 15.

The PPS Final Rule can be found via the Expert's Corner of AANAC's Web site, www.aanac.org.

Q: Resident was discontinued from rehab on 2/19/02, but skilled services continued with nursing, so he needed an OMRA. The 8-to 10-day window for the OMRA ARD is the 27th, 28th or 29th. He was also due for a Medicare 30-day assessment on 2/22/02. If I use grace days for the 30-day assessment, my ARD will be on 2/27/02, which is the 34th day of his Medicare stay. Is this OK?

A: Yes, you can use the 34th day for the 30-day, which is also within the 8- to 10-day window for the OMRA, so code the assessment as an OMRA, which will satisfy your 30-day requirement. The assessment indicator code for the bill would be 28, and payment changes on day 31 from a Rehab RUG to the identified RUG group created by the OMRA, since it is also a replacement assessment for the 30-day Medicare required assessment. Payment for the 30-day assessment starts on day 31, which is 2/24/02.

Q: If a resident exhausts her/his 100 days and continues to require the skilled service (such as a tube feeding), what is the code that is continued by the billing department until the skilled care ends?

A: When the 100-day benefit is exhausted, occurrence code A3 (FL 32 on the UB) is entered on the UB-92 claim form with the date of the 100th day. This lets the Fl know that the benefits are exhausted and on what date. In addition, the resident's status must be identified as "still a patient" via code 30 in FL 22. The combination of the two codes lets the FI know that a new benefit period should not be started, because as long as the resident continues to receive a skilled level of service in the SNF, he or she will not have the 60-day break in skilled services required to start a new benefit period.

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