MDS Alert

The right information can keep your facility fiscally on its feet.

Misconceptions about the 60-day break in the "spell of illness" can break your SNF's bottom line over time if staff often make the wrong Part A SNF coverage decisions.

The rule in a nutshell: Each Medicare Part A beneficiary is entitled to a 100-day benefit period for SNF services. "A benefit period begins with a three-day qualifying hospital stay during a month when the beneficiary is entitled to Medicare benefits," says Marilyn Mines, RN, RAC-C, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, IL. The benefit period ends when the beneficiary has not been in a SNF or an inpatient in a hospital for 60 days in a row -- or if he remains in a SNF, hasn't received skilled care there for 60 consecutive days. At that point, the beneficiary gets another 100-day benefit period.

It sounds fairly simple, but the devil lies in the details -- in this case, the interpretation. So watch out for these common scenarios that can pave the way for mistakes.

Scenario No. 1: A resident who had been receiving a non-skilled level of care gets sick and goes to the hospital for a three-day stay (three overnights) to receive treatment for a condition for which he received Part A-covered skilled care in the SNF 45 days ago. When readmitted to the SNF after his hospital stay, the resident requires daily skilled nursing care. He has 70 days left in his Medicare Part A SNF benefit period. Yet the SNF doesn't put him on Part A because he has the same condition for which he received treatment during his previous skilled stay.

Did they make the right coverage decision? No, experts say. "Often-times facilities believe a new diagnosis is needed," but that's incorrect, Mines says.

The converse can also occur: For example, some SNF staff will reason that even though the resident has used up his 100 days because he has a feeding tube, the SNF can cover him when he's admitted for a hip fracture, points out Christine Twombly, RNC, chief clinical consultant for Reingruber & Co. in St. Petersburg, FL. That's also false.

Scenario No. 2: A resident who exhausted his 100 days of coverage 70 days ago has had a couple of one-night inpatient hospitalizations a month apart during that time, although he hasn't received a skilled level of care in the nursing facility. He then develops pneumonia, goes to the hospital for three overnights and returns to the facility, which admits him for Part A skilled care.

The reality: Each of the resident's one-night inpatient rehospitalizations restarted the 60-day count for a break in the spell of illness.

Remember: Only an inpatient hospital stay interrupts the 60-day break, Mines stresses. "If the resident spent the night in the emergency department or in an observational stay, there would be no interruption in the 60-day count."

Scenario No. 3: Staff believes a resident receiving a tube feeding that meets the definition for skilled care is no longer "skilled" because he's stable and tolerating the feeding well. So they start the 60-day countdown toward a new 100-day benefit period.

The reality: As long as the resident is receiving 51 percent or more of his calories a day, or 26 to 50 percent of his calories and 501 cc or more per day of fluid via tube feeding, the tube feeding is considered a Medicare skilled level of care in the nursing home.

Watch out: Facilities sometimes believe that a resident receiving daily oxygen always continues to require skilled care after exhausting his 100 days of Part A SNF coverage. But "that's untrue if he's stable and not requiring daily skilled nursing care," advises Felice Landry, senior billing consultant for Reingruber & Co. in St. Petersburg, FL.

Scenario No. 4: A SNF resident who has exhausted his 100 days of coverage is discharged home for 60 days with a feeding tube that provides 75 percent of his caloric and fluid intake. He receives home health care for the tube feeding and other skilled care needs, including physical therapy. On day 62 of his stay at home, he falls and breaks his leg. Following a three-midnight hospital stay, he is admitted to the SNF with physician orders for daily rehab therapy. But the SNF doesn't cover him because he had a tube feeding and received home health services over the 60-day period at home.

The reality: The SNF is actually denying the person coverage to which he is entitled. That's because the "home is considered an unskilled setting and therefore the days [spent] at home counts as a break in the spell of illness. That's true even if the person has a home health nurse coming every day," Twombly says. Thus, the resident in this scenario had a 60-day break in the spell of illness and qualifies for another 100 days of Part A SNF coverage.

Track the days carefully: Twombly has, however, seen cases where the person who has exhausted his 100 days of coverage goes home for home health services and then goes back to the hospital on day 59. He's then admitted to the SNF after a three-night inpatient hospital stay, and it appears as if he's had a 60-day break in the spell of illness. "But the hospital stay interrupted the 60-day count," Twombly cautions.

Editor's note: Stay tuned for part 2 of this article on benefits exhaust claims and no-pay bills in the next MDS Alert.