Overview of Skilled Nursing and Medicare Part A


Skilled Nursing Facility Prospective Payment System
Plus, know more about Medicare’s practical matter criteria and presumptive coverage

There's some additional Medicare rules verbiage from Transmittal 262 which talks about the patient obtaining or maintaining their highest practical state of wellbeing. This is part of the goal of the Medicare program. So if you can determine that the patient has not attained their highest practice state of wellbeing, then that person continues to be at a skilled level of care.

Furthermore, there are no limits placed on services meaning that under the prospective payment system, there are 53 different RUG categories in which a patient will be placed into based on your MDS process.

So each RUG category has particular criteria for the patient to be placed in that RUG category. Well, the criteria state the minimum requirement to be in that RUG category. So we'll use therapy minutes as an example. If a patient requires 500 minutes of therapy to get into the rehab very high category, therapist certainly can provide more than 500 minutes for that patient.

And there no limits based on a patient’s diagnosis, based on a patient’s age, based on a patient’s RUG group as to what you can provide. You provide whatever the patient needs and requires which is also a fabulous part of the Medicare program because you are – have that lateral ability to make determinations, provide what the person needs and there's nobody over your shoulder as there is oftentimes with commercial insurances saying, “Are they done? Can you take them off? Okay, one more week.” But the facility has the ability to program plan within the whole 100 days which is a really nice program and it's a fabulous advantage for our Medicare patients.

Medicare Rules: Practical Matter Criteria

Medicare has what's called the practical matter criteria. And it states as a practice matter considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility.

Well, this is really important for us to remember as to understand because especially in the day and age of Medicare rules reviews and denials, if you are looking at a patient that you continue to skill, the intermediary or one of the Medicare reviewers send the facility a little love note as we like to call them and said, “Well, we're going to do an additional development on this particular claim. We want to see all the documentation on this claim.”

They look at it and say, “Oh, we don’t feel that this was medically reasonable and necessary and we're going to deny your payment.” Well, of course, the skilled nursing facility is going to appeal because we don’t provide services to our patients because we don’t feel that they're skilled. We provide them because we feel that they have met the Medicare criteria.

Well the practical matter criteria is verbiage and Medicare law in which you can return this verbiage in your appeal and provide this as support for why you would have skilled a patient.

Again, as a practical matter, if transportation would cause excessive physical hardship to the patient, maybe sending that patient to outpatient on a regular basis would put them at risk medically or as it says would cause excessive physical hardship. Then as a practical matter, they should be in the skilled nursing facility.

If there's no caretaker available or insufficient assistance at home, as a practical matter, the presence should be in the skilled nursing facility. So this is all great information for the facility to have if you are under a review and you need to support why you made that decision. As a practical matter, the patient could only have received services in your skilled nursing facility.

And most oftentimes that is the case. Now the interesting thing is that we also want to warn facilities not to interpret that too strictly that you don’t allow patients who has a temporary absence

It should be well documented. It should be physician, the leave of absence. And there should be documentation of teaching that occurred with the family or whoever the caretaker is going to be of that patient.

Medicare Rules: Presumptive Coverage

Presumptive coverage talks about when the patient’s initial five day PPS assessment results in one of the top 35 RUG scores. We  talked about 53 different RUG scores. When the MDS generates the RUG score, that’s in the top 35, Medicare says there is a presumptive coverage. They are going to presume that that patient is skilled, requires daily skilled care from the day of admission up to and including the ARD for that assessment.

Just by virtue of the fact that the patient generate a RUG score that’s in the upper 35. Now there's also the lower 18 RUG scores which could potentially mean that the patient is not skilled, not necessarily but your documentation must be pristine to support any patient whose RUG score is generated in the lower 18 score.

Okay. So any of your score is below, your clinically complex scores, your CA-1, that's your last score within your top 35. Below that is lower 18. And everyday, there should be a note that very clearly states what other skilled nursing service is being provided.

So presumptive coverage is also some great ammunition, if you will for utilizing as verbiage when the patient or when a claim is denied from an intermediary, you can utilize their own Medicare law and say, “Well, presumptive coverage.” Now, presumptive coverage remains in effect as long as there is supportive documentation and that the MDS is continued to generate in the upper 35 RUG scores.

Now what's interesting is there is no predetermined block of time. Again, this statement is from the final rule, that a patient will be skilled based on their RUG score, based on their diagnosis, based on their age. It's up to the facility to determine have their reached their highest practical level of wellbeing and if their medical regime is essentially stabilized.

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