(Medicare Benefit Policy Manual)

20.2 - Thirty -Day Transfer  (Rev. 1, 10- 01-03)  A3-3131.3, SNF -212.3   20.2.1 - General  (Rev. 161, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)  A3-3131.3.A, SNF-212.3.A  Post-hospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services.  Extended care services are post-hospital if initiated within 30 days after discharge from a hospital stay that included at least three consecutive days of medically necessary inpatient hospital services.  In certain circumstances the 30 -day period may be extended, as described in 20.2.2 below.  Even if a beneficiarys care during a qualifying hospital stay becomes less intensive during the latter part of the stay, the date of hospital discharge in this context is still considered to be the day that the beneficiary physically leaves the hospi tal, and the level of care being furnished at that particular point is not a determining factor as long as some portion of the stay included at least 3 consecutive days of medically necessary inpatient hospital services.   In determining the 30-day transfer period, the day of discharge from the hospital is not counted in the 30 days.  For example, a patient discharged from a hospital on August 1 and admitted to a SNF on August 31 was admitted within 30 days.  The 30-day period begins on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care.  Thus, an individual who is admitted to a SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30-day requirement. (See 20.2.2 below for an exception under which such services may be covered.)  Conversely, as long a s a covered level of care is  needed and initiated in the SNF within the specified timeframe, the timely transfer requirement is considered to be met even if actual Medicare payment  does not commence until later (for example, in a situation where another payment source that is primary to Medicare has assumed financial responsibility for the initial portion of the SNF stay).   If an individual whose SNF stay was covered upon admission is thereafter determined not to require a covered level of care for a period of more than 30 days, payment could not be resumed for any extended care services he or she may subsequently require, even though he or she has remained in the facility, until the occurrence of a new qualifying hospital stay.  In the absence of a new qualifying hospital stay, such services could not be deemed to be post-hospital extended care services. (For exception, see 20.2.2 below.)  20.2.2 - Medical Appropriateness Exception  (Rev. 1, 10-01-03)  A3-3131.3.B, SNF-212.3.B  An elapsed period of more than 30 days is permitted for SNF admissions where the patients 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.   20.2.2.1 - Medical Needs Are Predictable  (Rev. 1, 10- 01-03)  A3-3131.3.B.1, SNF -212.3.B.1  In determining the type of case that this exception is designed to address, it is necessary to recognize the intent of the extended care benefit.  The extended care benefit covers relatively short -term care when a patient requires skilled nursing or skilled rehabilitation services as a continuation of treatment begun in the hospital.  The requirement that covered extended care services be p rovided in a SNF within 30 days after hospital discharge is one of the means of assuring that the SNF care is related to the prior hospital care.   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 begi n 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 estab lished 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 dis charge 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.   An example of the type of care for which this provision was designed is care for a person with 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 ca re, 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 hospita l 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.  20.2.2.2 - Medical Needs Are Not Predictable  (Rev. 1, 10- 01-03)  A3-3131.3.B.2, SNF -212.3.B.2  When a patients 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.  For example, in some situations the prognosis for a patient diagnosed as having cancer is such that it can re asonably 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 ne eded.  Similarly, it is not known in what setting any future necessary services will be required; i.e., whether the patient will require the life -supporting services found only in the hospital setting, the type of care covered in a SNF, the intermittent ty pe of care which can be provided by a home health agency, or custodial care which may be provided either in a nursing home or the patients place of residence.  In some instances such patients may require care immediately and continuously; others may not r equire any skilled care for much longer periods, perhaps measured in years.  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.  20.2.2.3 - SNF Stay Prior to Beginning of Deferred Covered Treatment  (Rev. 1, 10- 01-03)  A3-3131.3.B.3, SNF -212.3.B.3  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.  (See example 1 below.)  However, 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 exte nded to include SNF care following an interval of more than 30 days of noncovered care (see example 2).  Where it is medically predictable that a patient will require a covered level of SNF care within a specific time frame, the fact that an individual ent ers a SNF immediately upon discharge from the hospital for noncovered care does not negate coverage at a later date, assuming the requirements of the law are met (see example 3).   EXAMPLE 1:   A patient who has had an open reduction of a fracture of the femoral neck and has a history of diabetes mellitus and angina pectoris is discharged from the hospital on January 30, 1991 and admitted immediately to a SNF.  He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to detect s igns of deterioration in his condition or complications resulting from his restricted mobility, which necessitates skilled management of his care to ensure his safety and recovery.  It is medically predictable that when he is medically allowed to bear weig ht on the affected limb, skilled rehabilitative services will be required.  After he is in the SNF for two days, he becomes unhappy and at his request is released to his home in the care of a full time private duty nurse.  Five weeks later, when he reaches  weight bearing, he is readmitted to the SNF for the needed rehabilitative care.  The patient would be eligible for coverage under the program for the care furnished him during both of these stays.   EXAMPLE 2:   An individual is admitted to a SNF for daily skilled rehabilitative care that, as a practical matter, can be provided only on an inpatient basis in a SNF.  After three weeks, the therapy is discontinued because the patients condition has stabilized and da ily skilled services are no longer required.  Six weeks later, however, as a result of an unexpected change in the patients condition, daily skilled services are again required.  Since the second period of treatment did not constitute care which was predi ctable at the time of hospital discharge and thus could not be considered as care which was deferred until medically appropriate, it would not represent an exception to the 30- day exception rule.  Therefore, since more than 30 days of noncovered care had e lapsed between the last period of covered care and the reinstitution of skilled services, payment could not be made under the extended care benefit for the latter services.   EXAMPLE 3:   A patient whose right leg was amputated was discharged from the hospital and admitted directly to a SNF on January 30, 1991.  Although upon admission to the SNF the patient required help with meeting his activities of daily living, he did not require daily skilled care.  Subsequently, however, after the stump had healed, daily skilled rehabilitative services designed to enable him to use a prosthesis were required.  Since at the time of the patients discharge from the hospital it was medically predictable that covered SNF care would be required at a predeterminable time interval, and since such care was initiated when appropriate, the patient would be entitled to extended care benefits for the period during which such care was provided.   20.2.2.4 - Effect of Delay in Initiation of Deferred Care  (Rev. 1, 10- 01-03)  A3-3131.3.B.4, SNF -212.3.B.4  As indicated, where the required care commences within the anticipated time frame, the transfer requirement would be considered met even though more than 30 days have elapsed.  However, situations may occur where complications necessitate delayed initiation of the required care and treatment beyond the usual anticipated time frame (e.g., skilled rehabilitative services which will enable an amputee patient to use a prosthetic device must be deferred due to an infection in the stump).  In such situations, the 30-day transfer requirement may still be met even though care is not started within the usual anticipated time frame, if the care is begun as soon as medically possible and the care at that time is still reasonable and necessary for the treatment  of a condition for which the patient received inpatient hospital care.