In our industry, we have all read it numerous times.
Some of us can quote portions of it in our sleep… three consecutive calendar days, for a condition that was treated during the qualifying hospital stay or arises, daily skilled services, as a practical matter… and the list goes on.
It is after all the foundation for understanding the rules and regulations related to accessing the Medicare Part A
Everything starts with CMS 100-2 Chapter 8.
Today I want to explore a lesser quoted component of Chapter 8 in the “Medical Appropriateness Exception.”
Specifically, regarding access the manual states: The beneficiary must also have been transferred to a participating SNF within 30 days after discharge from the hospital unless there is a Medical Appropriateness Exception.
What exactly is medical appropriateness?
How does this apply to your patient population?
Are there ways we can care for patients and transition them to their least restrictive environment more effectively in our communities via this exception?
Let’s explore more.
Your key words and phrases for this element include deferred care, at the time of discharge, predictability, and acceptable standards of medical practice.
Medical Appropriateness Exception is located in section 20.2.2 and includes the following considerations:
- 188.8.131.52 Medical Needs Are Predictable
- 184.108.40.206 Medical Needs Are Not Predictable
- 220.127.116.11 SNF Stay Prior to Beginning of Deferred Covered Treatment
- 18.104.22.168 Effect of Delay in Initiation of Deferred Care
- 22.214.171.124 Effect on Spell of Illness
First, we must understand what is meant by a “Medical Appropriateness Exception.”
Specifically, an elapsed period of more than 30 days is permitted for SNF admissions where the patient’s condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a predeterminable time-period.
The fact that a patient enters a SNF immediately upon discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.
Second, we must appreciate what is meant by “Medical Needs Are Predictable.”
This exception to the 30-day requirement recognizes that for certain conditions, SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge.
Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it is applicable only where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame.
Accordingly, to qualify for this exception it must be medically predictable at the time of hospital discharge that a covered level of SNF care will be required within a predictable period of time for the treatment of a condition for which hospital care was received and the patient must begin receiving such care within that time frame.
Consider the case study below:
An individual suffers a hip fracture. Under the established pattern of treatment of hip fractures, it is known that skilled therapy services will be required subsequent to hospital care and that they can normally begin within four to six weeks after hospital discharge, when weight bearing can be tolerated.
Under the exception to the 30-day rule, the admission of a patient with a hip fracture to a SNF within 4 to 6 weeks after hospital discharge for skilled care, which as a practical matter can only be provided on an inpatient basis by a SNF, would be considered a timely admission.
Take home point here – access and use of medical exceptions will require effective communication with your acute care partners to identify individuals who have medically predictable needs at time of discharge.
Ok, easy enough. Now what about when the “Medical Needs Are Not Predictable”?
When a patient’s medical needs and the course of treatment are not predictable at the time of hospital discharge because the exact pattern of care required and the time frame in which it will be required is dependent on the developing nature of the patient’s condition, an admission to a SNF more than 30 days after discharge from the hospital is not justified under this exception to the 30-day rule.
Consider the case study below:
In some situations, the prognosis for a patient diagnosed as having cancer is such that it can reasonably be expected that additional care will be required at some time in the future.
However, at the time of discharge from the hospital it is difficult to predict the actual services that will be required, or the time frame in which the care will be needed.
Therefore, since in such cases it is not medically predictable at the time of the hospital discharge that the individual will require covered SNF care within a predeterminable time frame, such cases do not fall within the 30-day exception
Next, let’s consider what the regulations say about cases where there is a need for a SNF stay prior to beginning of deferred covered treatment.
In some cases where it is medically predictable that a patient will require a covered level of SNF care within a predeterminable time frame, the individual may also have a need for a covered level of SNF care within 30 days of hospital discharge.
In such situations, this need for covered SNF care does not negate further coverage at a future date even if there is a noncovered interval of more than 30 days between the two stays, provided all other requirements are met.
The key here however is that this rule applies only where part of the care required involves deferred care, which was medically predictable at the time of hospital discharge.
If the deferred care is not medically predictable at the time of hospital discharge, then coverage may not be extended to include SNF care following an interval of more than 30 days of noncovered care
Finally, let us consider the effect on spell of illness.
In the infrequent situation where the patient has been discharged from the hospital to his or her home more than 60 days before he or she is ready to begin a course of deferred care in a SNF, a new spell of illness begins with the day the beneficiary enters the SNF thereby generating another 100 days of extended care benefits (see Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, section10.4.1).
Another qualifying hospital stay would not be required, providing the care furnished is clearly related to a hospital stay in the previous spell of illness and represents care for which the need was predicted at the time of discharge from such hospital stay.
Everything starts with CMS 100-2 Chapter 8.
Deferred care, at the time of discharge, predictability, and acceptable standards of medical practice are all areas to consider for medical appropriateness.
Hoping all will take some time to review these options, consider the benefit of their use in serving patients in your own communities.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.