Tube Feeding & 60 day spell of wellness

In order to be eligible for a new "benefit period" the resident must not have received skilled services while in the nursing home for 60 consecutive days nor admitted to a hospital during that period.

Tube feeding that comprises 26% KCal and 501 ml fld or more /day is a skilled service (less than that is not). Therefore, the continually tube-fed resident will never be eligible for a new benefit period.

If the resident went home and was at home for 60 consecutive days while being tube-fed, then he will be entitled to a new benefit period when he is again admitted to the SNF after a 3-day hosp. stay.

See this Q&A p2 #4 from an FI

For consumers Medicare Coverage of Skilled Nursing Facility Care pp 14-15

You need to remember that reason for covering them must be related to the 3 day stay. If this resident goes our for pneumonia then the G-tube at this point which is no longer a new g-tube and is not related to the 3 day stay.

This is an excellent reference: For consumers Medicare Coverage of Skilled Nursing Facility Care pp 14-15


For consumers Medicare Coverage of Skilled Nursing Facility Care pp 14-15


as posted above.

If you are in doubt and need someone to confirm your decision making you can always call your state rep.

The admissions coordinator or marketing person should also be up on this.

Check out the reference it is what Medicare recipients receive to read to know what their benefits are.

Calli

I was understanding until the post of January 13 which states... "You need to remember that reason for covering them must be related to the 3 day stay. If this resident goes our for pneumonia then the G-tube at this point which is no longer a new g-tube and is not related to the 3 day stay."

Does this mean that if a person (who has continually been on a feeding tube) returned to the SNF requiring "skilled care for the pneumonia" could then qualify for new benefit period?
or does it mean it really does not matter what the new/additional nursing care is related to, they are automatically disqualified from a new benefit period. This is because of the feeding tube makes it so it is still considered part of the same benefit period.

Thank you for your time...

This can be confusing. Talino's response on January 7th was the short, succinct "cliffs notes" version. Here is the encyclopedia version--

DAILY SKILLED CARE IS DAILY SKILLED CARE--no matter what diagnosis/diagnoses the person has which requires/require daily skilled care.

A person who has received, and continues to require and receive, primary nutrition by gastrostomy tube feedings, for years (in your SNF or another SNF following a previous 3 day qualifying hospital stay and 100 days of SNF coverage) will never again qualify for MC A SNF benefits if he/she continually resides in your facility or another SNF. He/she may have a 20 day hospital stay for pneumonia and now require a ventilator--a new diagnosis or need for an additional skilled service does not create a new "spell of illness"--if the person had continually received ANY daily inpatient skilled service.

If he/she goes home, stays home, receives daily TF at home, and does not require inpatient hospital or SNF services for 60 consecutive days/nights, he/she WILL be eligible for a new "spell of illness." (Home-health daily skilled services are not inpatient services) He/she had a 60 day period of wellness.

If he/she then goes to the ER on day 61, and requires and is admitted for a 3 day inpatient hospital stay for sepsis secondary to UTI, and also continues to require and receive primary nutritional support via tube feedings in the hospital, and is transferred and admitted to your SNF for IVAB (and still requiring primary nutrition via gastrostomy feedings)--he/she is eligible for 100 "new" days of MC A SNF coverage--he/she has a new "spell of illness". MC A SNF coverage is allowed for any required daily skilled service related to a condition treated (or for which services were provided) during the hospital admission, or for any condition which arose during the SNF stay (following the hospital admission.) It does not matter whether the service is "old" or "new". He/she may require daily skilled IVAB therapy (as well as TF) for only 5 days, but he/she can be covered for a total of 100 days for required primary nutritional support via gastrotomy tube feedings (meeting skilled criteria) administered daily by licensed staff--since he/she also required, and the hospital provided, tube feedings during the hospital stay.

The same principle would apply to a 109 year old long term resident who develops an in-house stage 3 ulcer, despite all normal and extraordinary interventions. This person had required no other daily skilled service for 60+ days (actually 16+ years since successful rehab for a fractured hip). He/she develops a stage 2 ulcer which rapidly advances to a stage 3 ulcer requiring daily dressing changes by a licensed nurse (a skilled service) and is admitted for a 3 day inpatient hospital stay (during which the ulcer is dressed B.I.D) for painful arthritic changes and potential dislocation of fixation site. He/she is re-admitted back to your SNF--and is eligible for 100 MC A SNF days if he/she requires any daily skilled service "connected" to, or treated during, the hospital stay.

In this case, he/she will require and receive daily dressing changes by a licensed nurse to the now stage 4 tunneled and MRSA infected ulcer--until his/her "sudden" death on day 22.

Not everyone who has Medicare Part A meets SNF eligibility requirements (medically necessary 3 day inpatient hospital stay, need for medically necessary daily inpatient skilled service), or utilizes all available MC A SNF days. Some persons, through periods of wellness, create and utilize multiple MC "spells."

MC A SNF--Many Confusing Areas Sorely Needing Fore-thought

Thank you for taking the time to write such a thorough explanation. I appreciate it.