Resumption of Medicare A Benefits here?

[jlottRN]

I have a long-term resident at a LTC facility whom was hospitalized 5 nights and returned 6/21/12 under Medicare A with LLE Cellulitis. In addition to necessary nursing care, she continued on PT and OT for approx. 35 days and discontinued both PT and OT with her last covered tx/day 7/25/12.

She had a fall resulting in a Fx Left Shoulder and a Fx Left Pelvis 7/29/12 and returned to the facility in the early am hours on 7/30/12. She was ordered to be on bedrest for 3 days. PT plans to begin working with her again tomorrow, 8/02/12.

My question is... Is there any reason here she could not resume her Medicare A benefits upon admission, which I would consider her 36th day? This situation is a new one for me. Any advice would be appreciated!

[Talino]

medicare benefit policy manual chapter 8 - coverage of extended care services p.4

...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.

the therapies initially received were due to deconditioning related to the management of cellulitis. since the therapies were d/c'd, it is assumed the goals were met. resuming therapies for a totally new condition (fractures) depart from the definition above. another 3-day qualifying hosp stay would be required to qualify.

albeit a stretch, could the therapies have been d/c'd prematurely? poor endurance/gait instability/unsafe transfers contributed to the fall? then resuming rx may be tied back to the original condition, not the fx.

antsy? you can always look into med b.

[jlottRN]

Medically, the resident's primary Dx was LLE Cellulitis with additional PT treatment Dx of 781.2 - Abnormal Gait and OT treatment Dx of Generalized Weakness. While she indeed has resulting generalized weakness and an abnormal gait from the fall, I do not know what's approriate to tie the Cellulitis and Fractures together. As I said, this is a new one for me. I don't have many resources to brainstorm with issue with.

[Talino]

Since the new generalized weakness and gait abnormality is the result of a new condition (fracture), you technically cannot resume Med A. The resident would require a new 3-day hospital stay and treated for the fracture, returns to SNF, receives a new therapy eval and starts with a new treatment program for the after effects of the fracture.

What I meant initially w/ the "stretch" - If you conducted an investigation and the IDCP team indentifies the "root cause" w/ certainty that a recurrence of gait instability and gen. weakness resulted in a fall, then it would be undeniable that the resident should have continued with therapies. If he had been stronger and more stable, the fall wouldn't have happened. In that case, the gait instability and weakness can still be attributed to the original condition for which the resident was treated for during hosp'n - Cellulitis. Hence, resuming Med A w/ skilled therapies for that original condition/effect becomes appropriate. And, certainly extend the treatment further since the progress is now hampered by the fracture.