Mds/pps Q&a 001

  1. Scenario:

    A Medicare resident returned from a 3-day hospital stay on 2/01/02 due to Pneumonia and was covered for the 1st 14 days. Resident stabilized, coverage terminated on 2/14/02. On 2/17/02, nursing staff noticed decreased in ambulation endurance in the past 2 days. PT evaluation was done on 2/18/02 and the resident was started on Restorative PT for four weeks. It is deemed not to be a significant change in condition since resident is experiencing a recurrent arthritic flare-up. And since she's highly motivated improvement is favorable in just 2 weeks of therapy.

    If I resume/continue the Medicare assm't w/ a 14-day and use 5 days of grace period, that is, February 18th as the last day of observation period, the RUG score falls below Medicare eligibility requirements since there will be only 1day of therapy captured on Section P1b.

    What would you do?
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  2. 6 Comments

  3. by   tex
    How many medicare days does this resident have left? After a 3 day stay at the hospital, why wouldn't you upon return from the hospital, start the clock over again. Only if this resident hasn't used all of her medicare days for the year. Discharge her after she went to the hospital, then upon return, treat her as a new admission? With your 5 day and then 14 day. It is alot of paper work, but basically you already have an established care plan, minor adjustment to be done. Why wouldn't your therapy carry this resident at a higher rug rate? tex
  4. by   Talino
    Tex...

    I don't think you got the scenario right.

    There is only one hosp'n involved. The resident, on return, was Medicare covered for 14 days for a skilled need (s/p Pneumonia) which was subsequently discontinued. There was no Rehab rx required initially since the resident was obviously physically able until 2/17 when staff noticed a decline.

    The issue is how to capture the new RUGs which will be Rehab.

    Don't worry 'bout the care plans and paper works.
  5. by   Fran-RN
    If the resident is readmitted to medicare skilled care then you have to start with a 5 day assess again. there is a reference to this question in the medicare Q & A s on the ccm submission web site. Each time the resident is admitted to medicare after a break in coverage, even if there is no new hospital stay the assess clock starts over. You should time the assess so that you do capture the PT as that is the resource that is being used to cover them under medicare. We are allowed several days in the reference range to do just this , capture the resources that we are using and so get reimbursed for them. good luck!!!
  6. by   Catsrule16
    Remember your 30 day rule. You can pick this person up again if the decline is associated with the reason she needed skilled services. Did the assessments completed before coverage stopped reflect the decline in mobility? Was an OMRA assessment done when you D/C'd from skilled services? Was the arthritis flare up a direct result of her deconditioning due to having pneumonia? If that is the case, you can continue. Did you use all the grace days for your observation period?
    Last edit by Catsrule16 on Mar 16, '02
  7. by   Talino
    You do an OMRA after d/c from Rehab if there is a skilled nursing need.

    You don't need an OMRA after d/c from skilled nursing UNLESS there is a significant change. In this case an artrhitic "flare-up" is not a valid reason for a significant change, moreso if recovery is favorable in just 2 weeks of PT (as defined in RAI manual p2-8). Otherwise, you may need to do another SCSA in 2 weeks when the condition improves.

    The 30-day would apply if the lapse in assessment would be more than 5 days of the grace period allowed of the next PPS assm't. In which case, restarting the 5-day is no problem.

    In this scenario, wherein change in RUGs occured within the ARD window of the 14-day incldg. the grace days, the most logical reason is to restart the 5-day Medicare since you can use the projected dates of therapy, even tho P1b will only capture 1 day of rx.

    However, would you consider an arthritic flare-up related to pneumonia (the actual reason for skilled need) even tho the incident appeared more than 2 weeks after hosp return?

    Thanks for all the replies.
  8. by   Fran-RN
    I understand that if the resident had the dx of arthritis while hospitalized then an exacerbation of this condition ,which requires
    therapy, then qualifies them for medicare A coverage, since they are recieving a skilled service.

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Mds/pps Q&a 001