Medicare/SOT

[degravida5]

I had a resident that was previously Medicare, went to hospital, came back with orders for no therapy, so we made private pay, 5 day's after admit, started receiving therapy, do I initiate a SOT on day 7?

[HyzenthlayLPN]

No. As long as there is an acceptable medical diagnosis, get a doctor's order for Medicare Part A skilled services and do your certification (dated effective the day therapy began) and do a 5 day. An SOT is only needed if the resident is on a skilled nursing RUG and then begins therapy so the RUG can be changed to reflect therapy.

[degravida5]

Thank you for your response, there was nothing to skill them for on return, only need was therapy..and it was on hold...??

[degravida5]

Thank you for your response, there was nothing to skill them for on return, only need was therapy..and it was on hold...??

[HyzenthlayLPN]

Your primary skilled diagnosis needs to be a medical one. A person can get therapy as an out patient. Why does this resident need a skilled level of nursing care?

[degravida5]

She was receiving therapy before she went to hospital. Went to hospital after fall for surgery, did not get surgery and came back NWB and no therapy orders. Only had medicare as payor so no skilling need. She then had a f/u appointment that ordered therapy which we could skill for 5 day's after return from hospital. My thought was to do private pay first 5 day's and SOT/5day on day 7...???

[Talino]

30.1 – Administrative Level of Care Presumption p19

More than likely your resident meets the qualification of this guideline. This means if you created a PPS 5-day with ARD no later than day 8 of adm from hospital, the resident may have classified in the top 52 RUG category (no lower than Clinically Complex) and hence would have been paid by Medicare from day of Adm up to the ARD.

Since resident is placed on skilled therapy, create SOT w/ ARD within 5-7 days after the day of therapy eval'n which likely you will combine with 14-Day. The SOT Rehab RUG will be paid effective the day of therapy eval up to day 30.

To summarize

5-Day RUG - paid from day of Adm until the day before therapy eval

SOT/14-Day (ARD 5-7 days after therapy eval) - paid from day 1 of therapy eval until day 30

[degravida5]

Thank you sooo much!!!

[HyzenthlayLPN]

This resident was not skilled upon return (whether or not they COULD have been skilled)...there was no doctor's order for a skilled level of care, no certification for a skilled level of care and it is questionable whether the resident RECEIVED a SKILLED level of care. Deciding after 5 days "Oh, we coulda/shoulda/woulda skilled them" isn't in-line with Medicare guidelines. This is definitely something Medicare would have an issue with