Medicare 30 Day Window:
Return to Skilled Benefits within the Medicare 30 Day Window: Harmony reviews the process of re-accessing benefits within the Medicare 30 day window. The Medicare 30 day window is in place to allow a beneficiary access to remaining skilled days after a period of non-skilled level without requiring another 3 day qualifying hospital stay. In order to re-access benefits the new condition must be related to a condition or problem the resident received care for during the 3 day hospital stay or during the SNF stay following the 3 day hospital stay. Please refer to the Medicare Benefit Policy Manual, Chapter 8, Section 20.1:
- Ø To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, including services of an emergency hospital, or a condition, which arose while in the SNF, or for treatment of a condition for which the beneficiary was previously hospitalized.
- Ø The patient has a period of exacerbation or acute illness entitling access to remaining Part A days within the benefit period.
- Ø Complete the MDS to obtain a more accurate RUG level reflecting the current level of resource utilization and actual clinical status of the beneficiary.
Example 1: Patient at IBI when issued a notice of non-coverage. Returns to Part A within 30 day window for exacerbation of CHF. The patient is placed on oxygen and nebulizer therapy and requires daily skilled assessments.
- § Completing the return assessment in this scenario yields CC1 or SSC (with RT or skin captured).
- § The financial impact is as follows: CC1vs. MMQ = $253.58 - $185.00 = $68.58 x 14 days = $960.12 (potential starting the PPS schedule of assessments)
- § The financial impact of RT/Skin is as follows: SSC vs. CC1 = $279.40 - $253.58 = $25.82 x 14 days = $361,48 (potential with RT tracking)
The process of reviewing patients in the 30 day would benefit from further review. Harmony suggests additional education with the unit staff to assist in the identification of conditions that would require review by the team to determine if a return to skilled coverage is warranted.