You Qualify – No, You Don’t – Yes, You Do

on Tuesday, 24 September 2013. All News Items | Patient Status

The Medicare Benefit Policy manual (chapter 8, section 20) states, “In order to qualify for post-hospital extended care services (i.e. skilled nursing facility (SNF) services), the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days.” Sounds pretty straightforward, doesn’t it? Well, as usual with Medicare, nothing is as simple as it seems.

Cigna Government Services (CGS), the Medicare Administrative Contractor (MAC) for Jurisdiction 15 which includes Kentucky and Ohio, is implementing a service specific probe review for 3-Day Inpatient Stays resulting in a SNF admission. Although not specified in the probe announcement, I am sure they will be looking to verify that the care provided to the patient was medically necessary. Have you ever seen an admission order that read “Admit for 3 days for SNF admission” or something similar? I wouldn’t be surprised. And with aging parents of my own, I understand the frustration of families who can no longer provide the needed care to their relatives. I am sure they beg the patient’s physician to do something to help. But an inpatient “social” admission to simply have a three-day hospital stay is not appropriate. In fact, it is very inappropriate. CGS’s probe review is based on CERT findings, so it is likely CERT has identified some inappropriate 3-day admissions.

So hospitals would be wise to evaluate their own 3-day inpatient stays prior to SNF admissions. And the PEPPER reports are an excellent tool to assist hospitals. They include a tab for Three-day Skilled Nursing Facility-qualifying Admissions that compares your hospital’s data to your jurisdiction, state, and national data. You may want to pay special attention if your data is consistently a “high outlier”, trending upward over a period of time, or above the 80th percentile.

And if you listened to our IPPS webinar last week, you know the new 2014 rules address the SNF qualifying stay as it relates to the 2-midnight hospital admission benchmark and Part A to B rebilling. In determining if services meet the 2-midnight benchmark, physicians may consider any time already spent receiving outpatient services such as previous care in the emergency room or receiving observation services. However, this outpatient time cannot be counted toward meeting the 3-day qualifying stay for SNF admission. Only time after the patient is formally admitted is including in determining the 3 day stay.

If an inpatient admission is determined to not be medically necessary after discharge, the hospital may submit Part B inpatient and outpatient claims instead of billing for a Part A inpatient admission. Does this affect the SNF qualifying stay? In most cases, no. CMS explained in the 2014 IPPS Final Rule that the care can be medically necessary even though the inpatient admission is not. The only time a denied 3-day inpatient admission would not qualify for the SNF admission is when there is a “substantial departure from normal medical practice.” In other words, the care itself is not medically necessary, such as in the case of when the patient is admitted solely to “qualify” for the SNF placement.

Now the logic of these new rules does not seem to correlate, but the rules are what they are. At least for now!

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it. .


This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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