RE: acute care eval for snf

[Guest guest]

In our region, acute care assessments are required by some insurance and

by some managed Medicare plans in order to qualify for a SNF stay. Since

we don't know what insurance a patient has, we rely on our social

work/discharge planners to alert us to those patients. Regular Medicare

does not require an acute care assessment for SNF in this region.

Brownrigg

Inpatient Therapy Manager

Acute Care and Inpatient Physical Rehabilitation Therapies

PeaceHealth St. ph Medical Center

2901Squalicum Parkway

Bellingham, WA 98225

sbrownrigg@...

www.peacehealth.org

our success is in the being, not just the doing

From: PTManager [mailto:PTManager ] On

Behalf Of norma

Sent: Monday, February 28, 2011 12:15 PM

To: PTManager

Subject: acute care eval for snf

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@... <mailto:ngreenberg%40stanfordmed.org>

<mailto:ngreenberg@... <mailto:ngreenberg%40stanfordmed.org>

>

[Guest guest]

As far as I am aware, it is not Medicare requirement. Subacutes require it to

determine the rehab potential of the patient. More importantly use acute care

evals as a back up in case there are denials for payment. Private insurances and

managed medicare do require PT evals and treatment documentation to

authorize subacute services. It is a big issue at our hospital also.

 

Pam Eluri,PT,MS

Subject: acute care eval for snf

To: PTManager

Date: Monday, February 28, 2011, 3:14 PM

 

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...

[Guest guest]

As far as I am aware, it is not Medicare requirement. Subacutes require it to

determine the rehab potential of the patient. More importantly use acute care

evals as a back up in case there are denials for payment. Private insurances and

managed medicare do require PT evals and treatment documentation to

authorize subacute services. It is a big issue at our hospital also.

 

Pam Eluri,PT,MS

Subject: acute care eval for snf

To: PTManager

Date: Monday, February 28, 2011, 3:14 PM

 

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...

[Guest guest]

Norma

Medicare does not require an evaluation by PT, OT or SLP in the acute setting

prior to admission to an SNF. A three day stay in an acute is what qualifies

someone for Medicare A " Skilled " level of service in an SNF. There is a

" Presumption of Coverage " for anyone who has had the qualifying stay. That

coverage is for the first five days in an SNF to allow assessment of the needs

of a patient. Medicare A coverage in an SNF is determined by what the needs of

the patient are once admitted to the SNF not based on what the needs were in the

acute. This has been emphasized by the new MDS 3.0, which is no longer allowing

a look back that covers days in the acute as was allowed under MDS 2.0.

You may want to suggest your case management people speak with your MDS

Coordinator. The RAI manual will describe the conditions for coverage under RUG

IV. You may want to provide them with the appropriate pages. If you don't have a

copy you can download an electronic copy at the link below.

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

Ron Wall

Axiom Healthcare Group

Ontario, CA

To: PTManager

From: ngreenberg@...

Date: Mon, 28 Feb 2011 20:14:34 +0000

Subject: acute care eval for snf

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...

[Guest guest]

Norma

Medicare does not require an evaluation by PT, OT or SLP in the acute setting

prior to admission to an SNF. A three day stay in an acute is what qualifies

someone for Medicare A " Skilled " level of service in an SNF. There is a

" Presumption of Coverage " for anyone who has had the qualifying stay. That

coverage is for the first five days in an SNF to allow assessment of the needs

of a patient. Medicare A coverage in an SNF is determined by what the needs of

the patient are once admitted to the SNF not based on what the needs were in the

acute. This has been emphasized by the new MDS 3.0, which is no longer allowing

a look back that covers days in the acute as was allowed under MDS 2.0.

You may want to suggest your case management people speak with your MDS

Coordinator. The RAI manual will describe the conditions for coverage under RUG

IV. You may want to provide them with the appropriate pages. If you don't have a

copy you can download an electronic copy at the link below.

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

Ron Wall

Axiom Healthcare Group

Ontario, CA

To: PTManager

From: ngreenberg@...

Date: Mon, 28 Feb 2011 20:14:34 +0000

Subject: acute care eval for snf

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...

[Guest guest]

Ron,

I understand " presumption of coverage " , but hasn't " medical necessity " taken

over determination of payment for this level of care? For all levels of care?

I know our IP therapists are frequently asked to assess acute care patients for

discharge placement. Fewer and fewer patients are meeting the medical necessity

of a short term SNF stay and are going home with other services, (either home

health or even outpatient therapies). " Presumption of coverage " could become a

real issue when RACs will assess cases and could place the liability onto the

acute care hospital, denying SNF payment and hospital payment if certain

conditions aren't met. Does MDS 3.0 address this clearly?

Dan , PT

PT Manager

Vernon Memorial Hospital

Viroqua, WI 54665

dnelson@...

From: PTManager [mailto:PTManager ] On Behalf Of

Ron Wall

Sent: Monday, February 28, 2011 7:51 PM

To: PTManager Group

Subject: RE: acute care eval for snf

Norma

Medicare does not require an evaluation by PT, OT or SLP in the acute setting

prior to admission to an SNF. A three day stay in an acute is what qualifies

someone for Medicare A " Skilled " level of service in an SNF. There is a

" Presumption of Coverage " for anyone who has had the qualifying stay. That

coverage is for the first five days in an SNF to allow assessment of the needs

of a patient. Medicare A coverage in an SNF is determined by what the needs of

the patient are once admitted to the SNF not based on what the needs were in the

acute. This has been emphasized by the new MDS 3.0, which is no longer allowing

a look back that covers days in the acute as was allowed under MDS 2.0.

You may want to suggest your case management people speak with your MDS

Coordinator. The RAI manual will describe the conditions for coverage under RUG

IV. You may want to provide them with the appropriate pages. If you don't have a

copy you can download an electronic copy at the link below.

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

Ron Wall

Axiom Healthcare Group

Ontario, CA

To: PTManager <mailto:PTManager%40yahoogroups.com>

From: ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>

Date: Mon, 28 Feb 2011 20:14:34 +0000

Subject: acute care eval for snf

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>

<mailto:ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>>

[Guest guest]

Dan

Here is the response from CMS in the Final Rule on SNF PPS dated August 11, 2010

to a question about whether Presumption of Coverage was eliminated because a

look-back does not include acute stay factors.

" Finally, we do not agree that eliminating the look-back period to the hospital

stay eliminates the presumption of coverage, because even in the absence of the

lookback, it remains possible for a resident to be assigned on the initial

5-day, Medicare-required assessment to one of the RUGs that we have designated

as qualifying the resident for the presumption. "

The resident will still need to qualify for one of the " skilled " RUG levels and

yes a RAC may question whether the threshold of " Medical Necessity " was met.

There is risk but ultimately the choice to treat a patient at any of these

levels comes down to sound, defendable clinical judgement. Whether the

justification is medical necessity, reasonable and necessary or requiring the

skills of a licensed professional, it has to be defendable clinically.

What is done at the acute does not dictate what is done in the SNF but needs to

be taken into consideration when designing the care plan. Liability for what

happens in the SNF will not be passed onto the acute however if a

non-appropriate stay occured in the acute I'm not sure how a RAC may view the

following SNF stay. I have heard of some acute stays that a RAC denied payment

for that were followed by SNF stay that did not result in a denial of payment to

the SNF. I'd be interested to hear what others may know.

Ron Wall

Axiom Healthcare Group

Ontario, CA

To: PTManager

From: dnelson@...

Date: Tue, 1 Mar 2011 08:52:28 -0600

Subject: RE: acute care eval for snf

Ron,

I understand " presumption of coverage " , but hasn't " medical necessity " taken

over determination of payment for this level of care? For all levels of care?

I know our IP therapists are frequently asked to assess acute care patients for

discharge placement. Fewer and fewer patients are meeting the medical necessity

of a short term SNF stay and are going home with other services, (either home

health or even outpatient therapies). " Presumption of coverage " could become a

real issue when RACs will assess cases and could place the liability onto the

acute care hospital, denying SNF payment and hospital payment if certain

conditions aren't met. Does MDS 3.0 address this clearly?

Dan , PT

PT Manager

Vernon Memorial Hospital

Viroqua, WI 54665

dnelson@...

From: PTManager [mailto:PTManager ] On Behalf Of

Ron Wall

Sent: Monday, February 28, 2011 7:51 PM

To: PTManager Group

Subject: RE: acute care eval for snf

Norma

Medicare does not require an evaluation by PT, OT or SLP in the acute setting

prior to admission to an SNF. A three day stay in an acute is what qualifies

someone for Medicare A " Skilled " level of service in an SNF. There is a

" Presumption of Coverage " for anyone who has had the qualifying stay. That

coverage is for the first five days in an SNF to allow assessment of the needs

of a patient. Medicare A coverage in an SNF is determined by what the needs of

the patient are once admitted to the SNF not based on what the needs were in the

acute. This has been emphasized by the new MDS 3.0, which is no longer allowing

a look back that covers days in the acute as was allowed under MDS 2.0.

You may want to suggest your case management people speak with your MDS

Coordinator. The RAI manual will describe the conditions for coverage under RUG

IV. You may want to provide them with the appropriate pages. If you don't have a

copy you can download an electronic copy at the link below.

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

Ron Wall

Axiom Healthcare Group

Ontario, CA

To: PTManager <mailto:PTManager%40yahoogroups.com>

From: ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>

Date: Mon, 28 Feb 2011 20:14:34 +0000

Subject: acute care eval for snf

Does medicare require a PT & /or an OT evaluation in the acute care

setting for acceptance in a snf for rehabilitation services. Case

management is pushing this issue and I do not feel that it is supported

in focuments from CMS or my fiscal intermediary in CA.

Your assistance is appreciated.

Norma Greenberg CPHQ, OTR/L

Quality and Compliance Supervisor

Respiratory and Rehabilitation Services

S T A N F O R D U N I V E R S I T Y H O S P I T A L + C L I N I C S

email | ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>

<mailto:ngreenberg@...<mailto:ngreenberg%40stanfordmed.org>>