More than a Century of Legal Experience

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1 Swing Bed Services: 3 Day Qualifying Stays, Medically Necessary Admissions, and Observation Services Oh My!!! August 13, 2013 Presented by: Jennifer McManis More than a Century of Legal Experience This document is the property of Crowley Fleck, PLLP and is not to be reproduced or distributed without permission. Agenda Benefit Extended Care Services Swing Bed Concept Benefit Level Of Care Prior Hospitalization & Transfer Requirements Level of Care Criteria Questionable Services Physician Certification & Recertification Documentation Requirements Admission &Discharge Orders Medical Necessity & Conditions of Participation Benefit Period Benefit Period Notice of Non-Coverage SNF ABN & HINNs Services Benefit Resources Resources Services Assessment Services Benefit Period Analysis 1

2 Extended Care (SNF )Benefit For treatment of a condition for which a patient was receiving inpatient hospital Services or a condition which arose in the SNF for treatment of a condition for Which a patient was previously hospitalized. Extended Care Services Post hospital services that are an extension of care for which inpatient hospital services were received Swing Bed Concept Allows a CAH to use their beds interchangeably CAH Swing Bed Requirements Received approval from CMS to operate Swing Beds Comply with CoPs, Special Requirements for Swing Bed Services Excluded from SNF PPS Benefit Inpatient: Hospital Specific Documentation Requirements Needed to Swing Inpatient: Skilled Nursing Facility 2

3 Benefit Benefit 100 Days of Skilled Care per Benefit period 1 st 20 Days are covered in full Days co-insurance is required No Lifetime Benefit No limit to the number of benefit periods Benefit period ends when the patient has been neither an inpatient of a hospital or a SNF for 60 consecutive days CAHs: No LOS Limit 100 Covered Days Per Benefit Period Benefits Break in SNF care for: Less Than 30 Days New 3-Day Stay is not needed Lasted for less than 60 days in a row, current benefit period will continue Maximum coverage available is the number of unused days at Least 30 but less than 60 Days New 3-Day Stay is Required Break lasted for less than 60 days in a row Maximum coverage available is the number of unused days At Least 60 New 3-Day Stay is Required Days N D S i R i d Break lasted for at least 60 days in a row Maximum coverage available is 100 Days 3

4 Extended Care (SNF) Benefit Extended (SNF) Level Of Care Extended (SNF) Level Of Care Prior Hospitalization & Transfer Requirements Think 3 midnights 3-Day Inpatient Qualifying Stay Observation Time prior to Medically Necessary Inpatient Stay Inpatient Admissions does not count Day of Admission is counted not day of Discharge Does not need to be in a hospital with which there is a transfer agreement Considered Post Hospital if: Initiated within 30 days of discharge Readmissions to the same or another SNF within days 1-30 do not require another qualifying stay 30 Day count begins on the day following discharge Exceptions to 30 Day Requirement Medical Appropriateness Exception Needs Are Predictable Certain conditions that require SNF care but cannot be initiated within 30 days after discharge 4

5 Level of Care Medical Predictability Exceptions to the 30 Day requirement Scenarios Scenario 1 ORIF of femoral neck; HX of DM Discharged from Inpatient Stay and required Skilled Care at time of discharge After two days of SNF care patient decides to leave and receive care at home with a Private Duty Nurse 5 weeks later is able to bear weight and is readmitted for SNF care of the fracture Exception Applies Scenario 2 Received three weeks of SNF care Discharged because SNF care was no longer needed Six week later there was an unexpected change in the patient s condition which required SNF care Exception Does Not Apply Scenario 3 Patient had a right leg amputation at another facility Discharged from the hospital and transferred to a SNF closer to their home, received two weeks of skilled care and was discharged. Required SNF care after the stump was healed, 8 weeks later Exception Applies Level of Care Think: When is the skilled service needed, not why. Understand: Patient s Condition is not the Sole Factor in determining if a service is Skilled Skilled Service Service that is complex that is ordered by a physician & can only be performed safely under the supervision of skilled nursing or rehabilitation staff Service that is ordinarily considered nonskilled could be considered a skilled service in cases in which required skilled nursing or skilled rehabilitation personally to perform Additional documentation required to support Level of Care Criteria Skilled Nursing or Skilled rehabilitation services must be needed & provided d 7 days a week or Skilled Rehabilitation services at least 5 Days a week Patient who is inpatient for skilled rehab services would meet the daily basis when provided at least 5 days a week Daily basis requirement can be met by furnishing a single type of skilled service every day Not applied so strictly, if there was an isolated break of a day or two during which no SNF was provided d but it is not reasonable for the patient to be discharged Restorative Skilled Nursing Services 6 days a week 5

6 Level of Care Skilled Services Management & Evaluation of a Patient Care Plan Observation & Assessment of Patient s Condition Teaching & Training Activities Direct Skilled Nursing Services Skilled Physical Therapy Skilled Speech Therapy Skilled Occupational Therapy Not Skilled Services For Example: Administration of Oral Meds General maintenance care of colostomy Routine services to maintain indwelling bladder catheters Dressing changes for uninfected post-operative conditions Use of heat as a palliative comfort measure Assistance in dressing and eating Periodic turning and position in bed General supervision of exercises unless part of a restorative maintenance program Level of Care QUESTIONABLE SERVICES Primary Service Needed is the Administration of Oral Medicine Patient is capable of independent ambulation, dressing, feeding, and hygiene Ordering a single type of skilled service every e day just to meet the requirement ement Documentation does not support the need for skilled personnel for a non-skilled service 6

7 Benefit Level of Care Documentation Requirements Documentation Requirements Conditions of Participation Same Chart may be utilized; must have a separate section Admission orders, discharge orders, progress notes, supporting documents, and discharge summary Meet the specific SNF requirements, i.e. resident rights, comprehensive assessment, free choice, comprehensive care plan Physician Certification & Recertification Initial within 14 days Recertification every 30 days Signed by the Physician or PA, NP Indicate services are required, estimated period of time required, and any plans if needed for home care Medical Necessity Documentation supports the need for skilled care & ordered by a physician Rendered for a condition for which the patient received inpatient care Required on a daily basis Can be provided only on an inpatient basis Reasonable & Necessary for the condition Admission & Discharge Orders Discharge Order from Acute Inpatient Hospital Stay Admission Order for Inpatient SNF Services 7

8 Benefit Level of Care Documentation Requirements Benefit Period Benefit Period Benefit Period Begins Date of Admission 100 Days Per Benefit Period Benefit Period Ends Patient has not been an inpatient of a hospital or SNF for 60 consecutive days or Remained in the SNF but did not receive skilled care for 60 consecutive days Once the Benefit Ends must have another 3 day qualifying stay 8

9 Notice of Non Coverage Benefit Period Different than the Important Message from Medicare Form CMS Given two days prior to the termination/end of services Deliver 2 days prior to discharge even if they agree with the termination of services Applies to Medicare & Medicare Advantage Combined to one notice ABN is given if the patient decides to continue with services once the decision has been made Do not give when benefits are exhausted or reduced Patient has right request an expedited review by the QIO; Form CMS If requested, did you deliver by close of business day the day you are notified Do not routinely ygive notice at the time services begin unless the service is expected to last fewer than two days SNF ABN & HINNs Given to the patient at the time that they want to continue or request extended care (SNF) services that are no longer medically necessary Benefit ABN, Hospital Issued Notices of Noncoverage (HINN), Notice of Medicare Non-Coverage (NOMNC), & Detailed Explanation of Non-Coverage (DEONC) Inpatient of a Hospital: Part A Inpatient Extended d Care: Part A 9

10 Inpatient Services Important Message from Medicare HINN 10: HRR HINN 11: Noncovered Service SNF Part A Services ABN Form CMS or Denial Letters SNF Part B Services ABN Form CMS-R-131 Detailed Notice of Discharge HINN 1: Preadmission HINN 12: Continued Stay Termination Notice NOMNC CMS HINN 1/*Letter 9(a)-(c) Preadmission FORMS ABN, HINNs, NOMNC,& DENC *HINN Letters 2-9 Retired PT Request Review of Termination DENC CMS HINN 12/*Letters 3-4; 6-7 Swing Bed Combination Letter Continued Stay Benefit The differentiation of when to use a HINN is most difficult for swing beds 10

11 1 st Form of communication when SNF care is no longer needed Benefit Notice of Noncoverage Use when covered skilled care is ending not when benefit is exhausted Use when there is a reduction in service ABN Use when care is ending Services HINN 1/*Letter 9(a)-(c): Preadmission Issued: before providing non-covered NF services provided in a swing bed Physician Concurrence not required Effective: At admission if given before 3:00pm SNF ABN Issued: to patients in a swing bed when services will be reduced or terminated and patient wants to continue with services Effective: Date Issued HINN12/ *Letter 3-4; 6-7: Continued Stay Issued: to a patient who chooses to remain in the hospital as an inpatient beyond the hospital determined discharge date Notice Content: Hospital Acute Care not covered Effective: Depends if the patient requests an Expedited Review Detailed Explanation of Non-Coverage (DENC) Issued: to patient who received a NOMNC and has requested a DENC Provide DENC by close of business day Notice of Medicare Non-Coverage & SNF ABN Issued: two days before the termination of services Patient may request an Expedited Determination Patient may decide to continue with services; issue a SNF ABN *HINN Letters Retired 11

12 Social Admits/Custodial Care Physician did not certify or recertify care refuses to certify 3-Day yq Qualifying Stay Not Met counting day of discharge More than 30 Days have passed since discharge from 3 Day Qualifying Stay Benefits Exhausted Benefit Period has ended NONC not given to patients Claim submitted for a 100 Days of SNF care but documentation does not support SNF care received Documentation from physician states patient no longer needs SNF care & is ready to go home Benefit Summary Level of Care Documentation Requirements Benefit Period Resources Resources: Services Resources Services Risk Assessment Services Benefit Period Analysis 12

13 This document is the property of Crowley Fleck, PLLP and is not to be reproduced or distributed without permission. Contact Information Jennifer McManis