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Medicare myths

Medicare myths

Editor’s note: This article is excerpted from the book Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement, by Elizabeth Malzahn-McLaren.


Throughout my years of educating providers on the inner workings of the Medicare program, whether it was a boot camp class for newcomers or a refresher course for those in the business for years, there are always instances where I am able to "myth-bust" Medicare. With any program, especially one that has been in existence for 60 years, there are bound to be some myths out there about how the program works.


Myth #1: A psychiatric resident will not qualify for Medicare Part A skilled services.

Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify coming straight from the hospital, at least for a short period of time.

First you need to determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.

The resident may need to have his or her medications adjusted; there also can be potential for an adverse drug reaction if medications were changed. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may have therapy orders upon discharge from the hospital. Other areas to review include hearing, speech, and vision (Section B of the Minimum Data Set [MDS]); ­cognitive patterns (Section C); mood (Section D); behavior (Section E); functional status (Section G); and medications (Section N) … just to name a few!


Myth #2: You can cover a resident for the first five days to observe and assess his or her condition.

The Centers for Medicare & Medicaid Services (CMS) provides no time frame of minimum or maximum time covered; however, there is the ability to use administrative presumption of coverage. Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD), if no skilled need is identified on the initial admission/readmission MDS. The regulation indicates that a resident can be skilled "until the condition of the patient is stabilized." Typically, skilled care for observation and assessment lasts for a few weeks or less.


Myth #3: A new diagnosis triggers a new benefit period.

This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service, and it can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under SNF Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria:

  • Determining when skilled services ended
  • Counting days

There is no magic formula to earning a new benefit period. Let us review an example to illustrate how the calculation should work.

A resident completed a 100-day Medicare benefit period on December 31. The resident remained skilled under Medicare Part B, receiving therapy services until January 31. Beginning February 1, the resident was no longer at a skilled level of care. Based on the counting of 60 days, the resident would be eligible for a new benefit period on April 2 (assuming 28 days in February). However, we need to review each day between February 1 and April 2 to make sure none of the following occurred:

  • Did the resident receive any services that would qualify the resident under a Medicare skilled level of care while in the SNF during that time period? For example, was the resident picked back up under a Medicare Part B plan of care that met the skilled level of care requirements?
  • Did the resident have any inpatient admissions to the hospital during that time period?


If the answer to either of these questions is yes, then the resident did not earn a new 100-day benefit period based on either the provision of skilled services or failure to meet the 60-day period of wellness requirement.

There is one small wrinkle in this calculation of benefit periods. If a resident leaves the SNF and continues to receive a skilled service while residing at home, for example, this would not impact the benefit period. When reviewing skilled services received, Medicare is only looking at skilled services received while in a SNF or as an inpatient of a hospital. Skilled services rendered to a beneficiary in the home setting do not impact the Medicare Part A SNF benefit period calculation.


Myth #4: All residents who are receiving tube feeding are always skilled and always will be skilled.

This statement is both true and false. The caveat lies with the level of calories and fluid the resident is taking in through the tube. Residents who meet the 26%?50% of calories and 501 cc of fluid per day via the feeding tube, or residents who receive 51% or more of calories via the feeding tube will automatically qualify for ­Medicare Part A benefits in a SNF. Additionally, they are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS. These levels will also continue that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.

Residents who meet the caloric and fluid requirements of 26%?50% of caloric intake and 501 cc of fluid daily via the tube or residents who receive 51% of more of caloric intake from the tube will remain at a skilled level of care for a full 100 days, as long as they remain at those levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she:

  • Drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF or inpatient hospital stay
  • Remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days


Myth #5: As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, we can pick the resident back up on Medicare Part A.

Although this is partly true, the most important criteria to using the 30-day window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.


Myth #6: A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.

Often, a resident is unable to leave the SNF due to the complexity of the services being rendered in the SNF. That said, a couple of items need to be reviewed before determining if an overnight leave of absence (LOA) is feasible:

  • Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF?
  • Are the absences infrequent in nature and not for prolonged periods of time?


Obviously, the first question is important to make sure the resident can be properly cared for during the LOA. It is always necessary to consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible. The second question relates more to being sure that the practical matter criteria also discussed in Chapter 3 is being met. If a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, for example, it is doubtful that the practical matter criterion is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02):

As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (see §30.7).


That said, although a resident may safely be able to go on LOAs frequently or for prolonged periods of time, the question becomes: Is the SNF the most appropriate place for that resident to receive those skilled services?


Myth #7: You never have to issue more than one notice regarding a Medicare stay at the same time.

If only that were a true statement. There are so many notices that it can be confusing trying to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Chapter 30, Section 261 of the Medicare Claims Processing Manual:

Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs. Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per §1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.


This same manual section notes the following example of when both notices would be issued:

A beneficiary’s Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverage. A SNFABN must also be delivered before custodial care begins.


Myth #8: There is never an instance where no notice is required at the end of Medicare coverage.

This is untrue! When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and have the ability to appeal decisions being made by providers in relation to their Medicare coverage; the end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. That said, it is recommended to communicate the end of the 100-day benefit period to the beneficiary, but no formal notice or form is required. – Billing Alert for Long-Term Care