Readmission Scenario

[stadells]

A quick re-admission scenario followed by question:

Resident is in a Medicare A bed but on Medicaid. He has a 3 day qualifying stay and meets all the criteria for Med A. However, the MDS Coordinator is not notified until the day after he returns to his Medicare A bed as Medicaid. A Utilization Review is held and the decision is made to begin Med A coverage that same day (the day AFTER admission). The order to begin Med A is written, dated the day AFTER admission. Accounting is notified that his first day back would be billed to Medicaid and his second day would be day 1 of Med A.

Now, my question is: Is it possible to start Med A the day after return? Keep in mind the resident is not changing beds when beginning Med A because he was already in one. Does this cause issues with billing? Is it assumed by Medicare that the resident did not necessitate skilled services because he was not receiving them on day 1?

I hope this isn't too confusing or too vague. I would truly appreciate any input.

[crissrn27, RN]

What skilled service are you picking him up on on day 2? Was it not present on admission?

[CapeCodMermaid, RN]

Why start on day 2? I was confused by your post, but I'm thinking Medicaid is NOT going to pay for a day if he were eligible for Medicare. Why not bill day one as Medicare?

[stadells]

Why start on day 2? I was confused by your post, but I'm thinking Medicaid is NOT going to pay for a day if he were eligible for Medicare. Why not bill day one as Medicare?

The order and precert were dated the day after he was readmitted at about 8 pm, even though the skilled service was present on admission. So that's a good point, why NOT bill day 1 as Medicare? Does it really matter that the dates don't match up? I'm not familiar with billing and this scenario has caused a ruckus that I don't quite understand and I can't seem to find any information elsewhere.

[edhcinc]

hi.

medicaid is the payer of last resort. as stated by capecodmermaid, medicaid will not pay for day 1 if also eligible for mc a and patient was in a mc certified bed.

you do not need an order "to begin med a." you need orders to provide direct skilled services, such as tube feeding, wound care, or rehabilitative therapy--but the order does not have to say that it is mc skilled tube feeding, mc skilled wound care, etc.

a mc a "denial" letter must be issued on admission if the patient has med a, but is deemed to be ineligible for mc a coverage--if not, no other payer can be billed. if the patient "rugs out" in one of the top 35 on the 5 day assessment, he/she is "presumed" to be coverable as of day 1 of admission. if the "skilled service was present on admission", the patient is entitled to use his/her mc a benefit--unless the patient had no admission orders and no licensed staff provided any care until day 2. (and in this case, also, the facility could not bill medicaid, either...)

what to do??

• d/c the order to start mca on day 2.
  
• write a new "late" order to begin skilled services on admission.
  
• make out a new certification form using the admission date as the "start" date--write "error--see cert dated ______" across the old one. the certification is not due on day 1 of admission--it is due "on admission" (what is a "pre-cert"??)
  
• if your facility does not use a certification form, the physician orders and physician notes should support the need for and type of skilled services provided.
  

a mc a admission coverage decision is not the sole responsibility of one person (the mds/pps coordinator). this decision must be reached before admission, or at admission by the admissions "team"--not one or two days later.

in this case, the error is easily correctable--facility can and should utilize the med a benefit for payment.

but in the reverse case (the patient has med a benefits and was admitted as med a skilled, but was deemed on day 2 to be non-coverable from admission) the facility cannot legally issue an admission mc "denial" letter. the facility may not legally bill medicaid for that day, either, since the facility did not provide the required beneficiary notification.

for complete snfpps info go to:

http://www.cms.hhs.gov/snfpps/

or the rai manual:

http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp

good luck!!