[nratchet]

My question is this....We have a patient who has chronic pressure ulcers due to being under weight and bed bound. She recently went to the hospital for a pathological fracture of the femur and returned Medicare. She is not appropriate for Physical Therapy because of her physical disabilities, one of which is rhemuatoid arthritis, can she be skilled for the wounds which she had prior to hospitalization. It is a situation that has never occured for us before and we are not sure what the answer is. Our Medicare coordinator says no, our assistant says yes and I am unsure.

Thanx for any help you can give.

[Talino]

The regulation says...

"The beneficiary must require SNF care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in the hospital."

Altho the hosp'n was due to fracture, the pressure ulcers would have been treated also during the stay. The clinical requirement is therefore met.

Now for the technical part -

1. Is the observation/treatment for the ulcers going to be provided on a daily basis?
If no, stop now, the resident does not qualify. If yes, proceed to #2.

2. Were these same ulcers treated daily prior to hospitalization?
If no, the resident is qualified.

But, if the same ulcers were treated daily prior to hospitalization, the service is considered skilled. Thus, the 60-day skill-free criterion must be met, that is, the resident must not be an inpatient of a hospital or has not received inpatient skilled care in a SNF for 60 days in order to earn a new benefit period (100 days).

[edhcinc]

Hi--Talino's statement is BASICALLY correct--with one caveat...we only have to consider whether or not a skilled service had been delivered daily before a hospitalization if THE PERSON IS ACTUALLY IN A BENEFIT PERIOD. That is, if the person used MC skilled days and continued to receive daily skilled care or began/resumed daily skilled care within 60 days of the days used or never used MC skilled days.

These are examples--put your patient into the right one:

1. Used 100 MC skilled days in January 2008 and has received daily skilled care since that date until 3 day hospitalization--same benefit period, no MC days available.
   
2. Used 20 skilled days ending January 31 2008; began daily skilled care "in-house" on March 15th (no MC days used because not within 30 day window); hospitalized for 3 days April 1, 2, 3rd; in same benefit period, 80 MC days available
3. Used 100 skilled days in 2007, last day November 15 2007. No daily skilled need until February 25 2007. Daily skilled need from that date until 3 day hospitalization on April 1, 2, 3; new benefit period since was NOT skilled for 60 days. 100 MC skilled days available.
4. Used 100 skilled days ending January 1 2005. Required daily skilled care beginning July 1 2006 until 3 day hospitalization in April 2008; same as #3.
5. Used 100 skilled days ending in January 1, 2007. Was hospitalized for 1 day the 15th of every month (blood transfusion) beginning February 15th throughout 2007. Began daily in-house skilled care on January 10th, 2008. 3 day hospitalization April 2008; benefit period never broken because person required care at a skilled level or greater at least one day within a 60 day period. No MC days available.
6. Admitted to NF 1/2005 from home. Received daily skilled care from July 2006 to present. (No MC days used, because no 3 day hospitalization) 3 day hospitalization April 2008; 100 skilled MC days available.

So, the caveat is whether or not the daily care to the chronic ulcers began IN a benefit period, or UNRELATED to a benefit period. :whe!:

Sometimes we make assumptions--we really need to go back and do some heavy research!! (these scenarios happen frequently with person who require tube feedings, too...)
Good luck!




"...technical part -...But, if the same ulcers were treated daily prior to hospitalization, the service is considered skilled. Thus, the 60-day skill-free criterion must be met, that is, the resident must not be an inpatient of a hospital or has not received inpatient skilled care in a SNF for 60 days in order to earn a new benefit period (100 days)."

[Rexie68]

This just goes to show how much confusion there is with Medicare, and how much training and knowledge we have to have. The staff nurses often think my job is "easy" and look down their noses at me 'cause I'm after them to rate pain, document behaviors, make sure there's an order for that dressing they're applying, etc. We're definitely a breed all of our own......

[edhcinc]

AGREED!!

Even after the more straight-forward MDS 3.0 is implemented, who "live and breathe" MC/PPS will survive!!