(Medicare Benefit Policy Manual)

30.7.3 - Whether the Patients Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative  (Rev. 1, 10- 01-03)  A3-3132.6.C, SNF -214.6.C   In determining the practicality of using more economical care alternatives, the A/B MAC (A) considers the patients medical condition.  If the use of those alternatives would adversely affect the patients medical condition, the A/B MAC (A) concludes that as a practical matter the daily skilled services can only be provided by a SNF on an inpatient basis.   If the use of a care alternative involves transportation of the individual on a daily basis, the A/B MAC (A) considers whether daily transportation would cause excessive physical hardship.  Determinations on whether a patients condition would be adversely affected if an available, more economical care alternative were utilized should not be based solely on the fact that the patient is nonambulatory.  There are individuals confined to wheelchairs who, though nonambulatory, could be transported daily by auto mobile from their homes to alternative care sources without any adverse impact.  Conversely, there are instances where an individuals condition would be adversely affected by daily transportation to a care facility, even though the individual is able to a mbulate to some extent.   EXAMPLE:  A 75 -year-old woman has suffered a cerebrovascular accident and cannot climb stairs safely.  The patient lives alone in a second -floor apartment accessible only by climbing a flight of stairs.  She requires physical therapy and occupational therapy on alternate days, and they are available in a CORF one mile away from her apartment.  However, because of her inability to negotiate the stairs, the daily skilled services she requires cannot, as a practical matter, be provided to the patient outside t he SNF.   The practical matter criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements, but who have occasion to be away from the SNF for a brief period of time.  While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, the fact that a patient is granted an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.  Where frequent or prolonged periods away from the S NF become possible, the A/B MAC (A) may question whether the patients care can, as a practical matter, only be furnished on an inpatient basis in a SNF.  Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.  (See the Medicare Benefit Policy Manual, Chapter 3, Duration of Covered Inpatient Services, 20.1.2, for counting inpatient days during a leave of absence.)   A conservative approach to retain the presumption for limitation of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage.  Such a notice is not appropriate.  If a SNF determines that covered care is n o longer needed, the situation does not change whether the patient actually leaves the facility or not.  40 - Physician Certification and Recertification  of Extended Care Services  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11 -08-21)  Payment for covered posthospital extended care services may be made only if a physician (or, as discussed in 40.1 of this chapter, a physician extender) makes the required certification, and where services are furnished over a period of time, the required recertification regarding the services furnished.   The SNF must obtain and retain the required certification and recertification statements.  The A/B MAC (A) may request them to assist in determining medical necessity when necessary.  The SNF will determine how to obtain the required certification and recertification statements.  There is no requirement for a specific procedure or form as long as the approach adopted by the facility permits verification that the certification and recertification requirement is met.  Certification or recertification statemen ts may be entered on or included in forms, notes, or other records that would normally be signed in caring for a patient, or on a separate form.  Except as otherwise specified, each certification and recertification is to be separately signed.   If the SNFs failure to obtain a certification or recertification is not due to a question of the necessity for the services, but to the physicians or physician extenders refusal to certify on other grounds (e.g., an objection in principle to the concept  of certification and recertification), the SNF cannot charge the beneficiary for covered items or services.  Its provider agreement precludes it from doing so.  If a physician or physician extender refuses to certify, because, in his/her opinion, the patient does not, as a practical matter, require daily skilled care for an ongoing condition for which he/she was receiving inpatient hospital services (or for a new condition that arose while in the SNF for treatment of that ongoing condition), the services are not covered and the facility can bill the patient directly.  The reason for the refusal to make the certification must be documented in the SNFs records.   Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see Pub.100 -04, Medicare Claims Processing Manual, Chapter 6, 120.2, regarding the circumstances under which a resumption of SNF care followi ng a temporary break in SNF coverage would be considered a new admission under the SNF PPSs interrupted stay policy).  The routine admission order established by a physician is not a certification of the necessity for post -hospital extended care services for purposes of the program.  There must be a separate signed statement indicating that the patient will require on a daily basis SNF covered care.   In addition, only physicians may certify outpatient physical therapy and outpatient speech -language pathology services.   40.1 - Who May Sign the Certification or Recertification for Extended Care Services  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nur se specialist (CNS) or, effective with items and services furnished on or after January 1, 2011, a physician assistant (PA)) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the phys ician.   In this context, the definition of a direct employment relationship is set forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under the regulations at 42 CFR 424.20(e)(2)(ii), when a physician extender has a direct employment relationship with an entity other than the facility, and the employing entity has an agreement with the facility that includes the provision of general nursing services under the regulations at 42 CFR 409.21, an indirect employment relationship exists between the physician extender and the facility. By contrast, such an indirect employment relationship does not exist if the agreement between the facility and the physician extenders employer solely involves the performance of delegated physician tasks under the regulations at 42 CFR 483.30(e).   Further information regarding certification and recertification of extended care services, including details on the content of the certification or recertification, timing of recertifications and the impact of delays on certifications and recertifications,  appears in Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Physician Certification and Recertification of Services, 40 - 40.6.  50 - Covered Extended Care Services  (Rev. 1, 10-01-03)  A3-3133, SNF-230  Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services.  Payment may be based on reasonable cost or be under the SNF Prospective Payment System (see 10).  The facility may charge the beneficiary for services they request that are not included in the PPS rate or otherwise covered by Medicare (i.e. extra meals for family members).   An inpatient  is a person who has been admitted to a skilled nursing facility or swing bed hospital for bed occupancy for purposes of receiving inpatient services.  A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged and do not actually use a bed overnight.  NOTES:   1.  Custodial care (see Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, 110) is not a covered extended care service.  2.  When patients requiring inpatient hospital services occupy beds in a SNF, they are considered inpatients of the SNF.  In such cases, the services furnished in the SNF may not be considered inpatient hospital services, and payment may not be made under the program for such services.  Such a situation may arise where the SNF is a distinct part of an institution the remainde r of which is a hospital, and either there is no bed available in the hospital, or for any other reason the institution fails to place the patient in the appropriate bed.  The same rule applies where the SNF is a separate institution.  For the same reason, where patients who require extended care services occupy beds in a hospital, payment cannot be made on their behalf for the services furnished to them in the hospital, unless the services are extended care services furnished pursuant to a swing bed approval.  (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 10.)  3.  When patients who require SNF services are placed in a noncertified part of an institution which contains a participating distinct part SNF, the services may be paid under certain conditions, based on the limitation of liability provisions.  (See Medicare Claims Processing Manual, Chapter 30, Limitation of Liability, 10.4.)  The extended care services in 50.1 - 50.9, below, are covered under hospital insurance.   50.1 - Nursing Care Provided by or Under the Supervision of a Registered Professional Nurse  (Rev. 1, 10- 01-03)  A3-3133.1, SNF -230.1   Nursing care provided by or under the supervision of a registered professional nurse is covered.   However, the services of a private -duty nurse or other private -duty attendant are not covered.  Private- duty nurses or private -duty attendants are registered professional nurses, licensed practical nurses, or any other trained attendant whose services ordi narily are rendered to, and restricted to, a particular patient by arrangement between the patient and the private -duty nurse or attendant.  Such persons are engaged or paid by an individual patient or by someone acting on their behalf, including a SNF tha t initially incurs the cost and looks to the patient for payment for such noncovered services.  Where the SNF acts on behalf of a patient, the services of the private- duty nurse or other attendant under such an arrangement are not extended care services regardless of the control which the SNF may exercise with respect to the services rendered by such  private -duty nurse or attendant.  50.2 - Bed and Board in Semi -Private Accommodations Furnished in Connection With Nursing Care  (Rev. 1, 10- 01-03)  A3-3133.2, SNF -230.2   (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 10.1, for provisions relating to inpatient accommodations.)   50.3 - Physical Therapy, Speech -Language Pathology, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)