Can he have a new stay of illness and be picked up under Medicare again?

By: April 13th, 2012 Email This Post Print This Post

Q: We have a resident who has received dialysis treatments for years, has used 100 Medicare days and is now beyond the wellness period, and was recently hospitalized for amputation. He has remained in the skilled nursing facility and has continued to receive dialysis treatments. Can he have a new stay of illness and be picked up under Medicare again?

A: I’m going to assume that the patient was considered benefits exhaust, but still skilled for the duration and that the UB-04 bills reflected this on a monthly basis. If this is the case, then the patient never accrued a new 100 days due to the lack of a break in skilled service. In this case, no new benefits are available under Medicare Part A until the patient goes 60 consecutive days without receiving skilled care and 60 days without a hospital admission (IOM-02 Medicare Benefits Policy Manual, Ch. 8, §30).

Comments

By marlene antones on April 14th, 2012 at 10:01 am

I am not quite clear on this. We have a resident Medicaid who is on dialysis at an outpatient facility and has been for over 2 years. Would this be considered “skilled services” or if he goes to the hospital for blocked AV shunt and returns with a Tessio cath am I able to capture this under Part A benefits??

By Jan Askins on April 16th, 2012 at 10:48 am

What is the dialysis or skilled service such as a tube feeding were present prior to the residnet becoming eligible for Medicare A benefits. If the skilled service received was not related to the Tube feed or dialysis (which it probably wasn’t if it was a previous condition, how would that affect the future skilling status.

By Rosemarie O'Gorman on April 16th, 2012 at 1:39 pm

I would like to comment on the new spell of illness for the dialysis patient who was hospitalized for an amputation. I would skill him if he had 60 days between his last spell of illness and a new 3 day hospital stay. The reason being that Medicare part A does not consider maintainence dialysis a skill and will not pay for it for 100 days in a Nursing Home. They pay for new dialysis until the patient becomes stable (shunt care etc.) as well as for education for the new dialysis ie. dietary restrictions etc. The patient may fall into a Clinically Complex RUG group due to the dialysis but this is no longer considered a daily skilled need once it is maintainence.

By Teresa Taylor on April 17th, 2012 at 12:39 pm

We do the dialysis residents the same as the last comment with med A available if qualifies and do not do full 100 for new dialysis residents only til stable also. I do have a question about the same thing but for tube fed residents- it was my understanding that after the initial 100 days med A benefit for new tubes that we may not skill with med A again even if it seems they are eligible with a welless period and qualifying hosp stay unless the tube is discontinued..Is this correct?

By Ginger Schuerger-Davison on April 23rd, 2012 at 11:02 am

I would tend to agree with the comments of Rosemarie O’Gorman, as it is my understanding that dialysis, in and of itself, is not necessarily a skilled service under SNF part A benefits.

 

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