evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
20.3.1.5 - Impact of Consolidated Billing Requirements  (Rev. 1, 10-01-03)  The SNF may not charge the beneficiary or family members for any services that, in the absence of a payment sanction, would have been covered under the SNF PPS.  However, the beneficiary is entitled to reimbursement for those services excluded from the SNF PPS rate.  Services excluded from consolidated billing such as outpatient hospital emergency care and related ambulance service should be billed by the provider/supplier actually furnishing services, and not by the SNF.  20.3.1.6 - Impact on Spell of Illness  (Rev. 1, 10-01-03)  The SNF days during the sanction period will be used to track breaks in the spell of illness.  A beneficiarys care in an SNF met the skilled level of care standards if a Medicare SNF claim for the services provided in the SNF was denied on grounds other than that the services were not at a skilled level of care.  If the patient is receiving a skilled level of care the benefit period cannot end.  30 - Skilled Nursing Facility Level of Care - General  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01 -07-14) A3-3132, SNF-214  Care in a SNF is covered if all of the following four factors are met:   The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see 30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;   The patient requires these skilled services on a daily basis (see 30.6 ); and    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.)
(Medicare Benefit Policy Manual)
 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.)   The services delivered are reasonable and necessary for the treatment of a patients illness or injury, i.e., are consistent with the nature and severity of the individuals illness or injury, the individuals particular medical needs, and accepted standar ds of medical practice.  The services must also be reasonable in terms of duration and quantity.  If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered.  For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than  daily skilled service.   In reviewing claims for SNF services to determine whether the level of care requirements are met, the A/B MAC (A)  first considers whether a patient needs skilled care.  If a need for a skilled service does not exist, then the daily and practical matter requirements are not addressed.  See section 30.2.2.1 for a discussion of the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.  Additional material on documentation appears in the various clinical scenarios that are presented throughout these level of care guidelines.  Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individuals potential for improvement from the nursing care and/or therapy, but rather on the beneficiarys need for skilled care.  Eligibility for SNF Medicare A coverage has not changed with the inception of PPS.  However, the skilled criteria and the medical review process have changed slightly.  For Medicare to render payment for skilled services provided to a beneficiary during a SNF Part A stay, the facility must complete an MDS.   EXAMPLE:  Even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be reasonable and necessary for the treatment of a patients illness or injury.
(Medicare Benefit Policy Manual)
EXAMPLE:  Even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be reasonable and necessary for the treatment of a patients illness or injury.   30.1  Administrative Level of Care Presumption  (Rev. 261, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)  Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are considered to meet the level of care requirements of 42 CFR 409.31 up to and including the assessment reference date (ARD) for the initial Medicare assessment prescribed in 42 CFR 413.343(b) , when correctly assigned one of the case -mix classifiers that CMS designates for this purpose as representing the required level of care.  While this assessment is commonly referred to as the 5 -day assessment (reflecting its original 5 -day assessment wi ndow), an additional 3 grace days have always been available beyond that window for actually setting the ARD; further, as of October 1, 2019, those additional 3 grace days are directly incorporated into the assessment window itself, thus resulting in an overall 8 -day assessment window.  The current set of case- mix classifier designations appears in the paragraph entitled Case Mix Adjustment on the SNF PPS web site, at https://www.cms.gov/Medicare/Medicare -Fe e-for-Service -Payment/SNFPPS/index.html. If the beneficiary is not admitted (or readmitted) directly to a SNF after a qualifying hospital stay, the administrative level of care presumption does not apply.
(Medicare Benefit Policy Manual)
For purposes of this presumption, the assessment reference date is defined in accordance with 42 CFR 483.315(d), and must be set for no later than the eighth day of posthospital SNF care.  Consequently, if the ARD for the initial Medicare assessment prescribed in 42 CFR 413.343(b)  is set for day 9, or later, the administrative level of care presumption does not apply.  The coverage that arises from this presumption remains in effect only for as long thereafter as it continues to be supported by the facts of the beneficiarys condition and care needs.  Accordingly, the SNF is expected to monitor carefully for and document any changes in the patients condition, in order to determine the continuing need for Part A SNF benefits after the ARD.  Moreover, this administrative presumption does not apply to any subsequent assessments.   To be correctly assigned, the data coded on the Resident Assessment Instrument (RAI) must be accurate and meet the definitions described in the Long Term Care Facility RAI Users Manual.  The beneficiary must receive services in the SNF that are reasonable and necessary.  Services provided to the beneficiary during the hospital stay are reviewed to ensure proper coding of the most recent version of the RAI.  The two examples illustrated below demonstrate a correct assignment and an incorrect assignment.   Incorrect Assignment :   IV med provided in hospital coded on MDS, but IV was for a surgical procedure only  as a consequence, the MDS is not accurate and the presumption does not apply (see Chapter 3, Section P of the RAI).  Correct Assignment:   Beneficiary is receiving oxygen therapy as well as rehab service.  The respiratory therapy services are found reasonable and necessary; however, the rehab services are found not reasonable and necessary, resulting in a revised case- mix classification.  Beneficiary was and is now correctly assigned  presumption applies.
(Medicare Benefit Policy Manual)
A beneficiary who is not assigned one of the case- mix classifiers designated as representing the required level of care on the initial Medicare assessment prescribed in 42 CFR 413.343(b)  is not automatically classified as meeting or not meeting the SNF level of care definition.  Instead, the beneficiary must receive an individual level of care determination using existing administrative criteria and procedures.  The following scenarios further clarify that a beneficiarys correct assignment of one of the case -mix classifiers that CMS designates for this purpose as representing the required level of care would serve to trigger the coverage presumption under the ini tial Medicare assessment only when that assessment occurs directly following the beneficiarys discharge from the qualifying hospital stay (i.e., the hospital discharge and subsequent SNF admission both occur on the same day) .  1.  Routine SNF Admission Directly From Qualifying Hospital Stay   If the beneficiary is admitted to the SNF immediately following a 3 -day qualifying hospital stay, there is a presumption that he or she meets the Medicare level of care criteria when correctly assigned one of the case- mix classifiers that CMS designates fo r this purpose as representing the required level of care.  The presumption lasts through the assessment reference date of the initial Medicare assessment, which must be set for no later than the eighth day of the stay.   2.  Admission to SNF does not immediately follow discharge from the qualifying hospital stay, but occurs within 30 days (as required under the 30 day transfer rule)   If the beneficiary is discharged from the hospital to a setting other than the SNF, the presumption of coverage does not apply, even if the beneficiarys SNF admission occurs within 30 days of discharge from the qualifying hospital stay.  Accordingly, cove rage would be determined based on a review of the medical evidence in the file.   3.  SNF Resident is Re -Hospitalized and Then Returns Directly to the SNF
(Medicare Benefit Policy Manual)
3.  SNF Resident is Re -Hospitalized and Then Returns Directly to the SNF   If a beneficiary who has been in a covered Part A stay requires readmission to a hospital, and subsequently returns directly to the SNF for continuing care, a new initial Medicare assessment under the regulations at 42 CFR 413.343(b) would be required if t he beneficiarys absence from the SNF exceeds the 3 -day interruption window specified under the SNF PPSs interrupted stay policy (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 6, 120.2).  In this scenario, there is a presumption that he or she meets the level of care criteria upon direct readmission from the hospital to the SNF when correctly assigned one of the case -mix classifiers that CMS designates for this purpose as representing the required level of care. The resulting presumption of coverage lasts through the assessment reference date (ARD) of that assessment, which must be set for no later than the eighth day of the stay.  Alternatively, if the absence from the SNF does not exceed the 3- day interruption window, the beneficiarys return to the same SNF would represent a continuation of the previous SNF stay; as such, there would be no new initial Medicare assessment and no new presumption of coverage; however, any days remaining from the previous presumption would continue to apply thr ough the ARD of the original assessment.   4.  Routine SNF Admission Directly From Qualifying Hospital Stay, but Initial Portion of SNF Stay Covered by Another Insurer (Medicare as Secondary Payer)
(Medicare Benefit Policy Manual)
4.  Routine SNF Admission Directly From Qualifying Hospital Stay, but Initial Portion of SNF Stay Covered by Another Insurer (Medicare as Secondary Payer)   When a beneficiary goes directly from a qualifying hospital stay to the SNF, but the initial portion of the SNF stay is covered by another insurer that is primary to Medicare, Medicare coverage would not start until coverage by the primary insurer ends.  Accordingly, the Medicare required assessment schedule would not begin until the first day of Medicare coverage.  If a beneficiary met the level of care criteria for Medicare coverage during the first 8 days of the stay following a qualifying hospital stay, and the other insurer covered this part of the stay, there is no presumption.  If Medicare becomes primary before the eighth day of the stay following a qualifying hospital stay, the presumption would apply through the assessment reference date on the ini tial Medicare assessment or, if earlier, the eighth day of the stay.   5.  Readmission to SNF Within 30 Days After Discharge From Initial SNF Stay  No Intervening Hospitalization  As noted in scenario 1, if a beneficiary is initially admitted to the SNF directly from the qualifying hospital stay for a covered Part A SNF stay, the presumption for that stay is applicable when the beneficiary is correctly assigned one of the case -mix c lassifiers that CMS designates for this purpose as representing the required level of care. However, if that beneficiary is discharged to a non -hospital  setting and then subsequently readmitted to the SNF beyond the 3- day interruption window as described i n scenario 3 above, there is no presumption applicable to the second SNF admission.  (If the beneficiary is transferred to a hospital, and returns directly to the SNF, see scenario 3 above). Alternatively, if the absence from the SNF does not exceed the 3 -day interruption window, the beneficiarys return to the same SNF would represent a continuation of the previous SNF stay; as such, any days remaining from the previous presumption would continue to apply through the ARD of the original assessment.  6.  Initial, Non- Medicare SNF Stay Followed by Qualifying Hospitalization and Readmission to SNF for Medicare Stay
(Medicare Benefit Policy Manual)
Dually eligible (Medicare/Medicaid) beneficiaries whose initial stay in the SNF is either Medicaid -covered or private pay, are eligible for the Medicare presumption of coverage when readmitted directly to the SNF following a qualifying hospitalization, whe n correctly assigned one of the case -mix classifiers that CMS designates for this purpose as representing the required level of care.  (Of course, in order to qualify for Medicare coverage upon readmission, the beneficiary must be placed in the portion of the institution that is actually certified by Medicare as a SNF.)  No presumption of coverage applies when Medicare is the secondary payer for days 1 through 8 of the covered stay where Medicare becomes primary after day 8 due to a reversal or denial by th e secondary insurer.   7.  Transfer From One SNF to Another   There is no presumption of coverage in cases involving the transfer of a beneficiary from one SNF to another or from SNF -level care in a hospital swing bed to a SNF.  The presumption only applies to the SNF stay that immediately follows the qualifying hospital stay when the beneficiary is correctly assigned one of the case -mix classifiers that CMS designates for this purpose as representing the required level of care.  Therefore, in cases involving transfer of a beneficiary from a swing -bed hospital to a SNF, the presumption only applies if the beneficiary was receiving acute care (rather than SNF-level care) immediately prior to discharge from the swing -bed hospital.  30.2 - Skilled Nursing and Skilled Rehabilitation Services  (Rev. 1, 10- 01-03)  A3-3132.1, SNF -214.1   30.2.1 - Skilled Services Defined  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that:    Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech- language pathologists or audiologists; and
(Medicare Benefit Policy Manual)
 Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech- language pathologists or audiologists; and    Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.   NOTE:   General supervision requires initial direction and periodic inspection of the actual activity.  However, the supervisor need not always be physically present or on the premises when the assistant is performing services.  Skilled care may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.  30.2.2 - Principles for Determining Whether a Service is Skilled  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.1.B, SNF -214.1.B    If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service; e.g., the administration of intravenous feedings and intramuscular injections; the insertion of suprapubic catheters; and ultrasound, shortwave, and microwave therapy treatments.    The A/B MAC (A) considers the nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service.  While a patients particular medical condition is a valid factor in deciding if skilled services are needed, a patients diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.  EXAMPLE:  When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed.  The deciding factor is not the patients potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by nonskilled personnel.  (See 30.5.)
(Medicare Benefit Policy Manual)
 A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient.  In these cases, the complications and special services involved must be documented by physicians' orders and notes as well as nursing or therapy notes.  EXAMPLE:   Whirlpool baths do not ordinarily require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required where the patients condition is complicated by circulatory deficiency, areas of desensitization, or open wounds.  The documentation needs to support the severity of the circulatory condition that requires skilled care (see section 30.2.2.1).   In determining whether services rendered in a SNF constitute covered care, it is necessary to determine whether individual services are skilled, and whether, in light of the patients total condition, skilled management of the services provided is needed even though many or all of the specific services were unskilled.  EXAMPLE:   An 81- year-old woman who is aphasic and confused, suffers from hemiplegia, congestive heart failure, and atrial fibrillation, has suffered a cerebrovascular accident, is incontinent, has a Stage 1 decubitus ulcer, and is unable to communicate and make her needs known.  Even though no specific service provided is skilled, the patients condition requires daily skilled nursing involvement to manage a plan for the total care needed, to observe the patients progress, and to evaluate the need for changes in the treatment plan.  As discussed in section 30.2.2.1 below, the medical condition of the patient must be described and documented to support the goals for the patient and the need for skilled nursing services.   The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.  EXAMPLE:   A primary need of a nonambulatory patient may be frequent changes of position in order to avoid development of decubitus ulcers.  However, since such changing of position does not ordinarily require skilled nursing or skilled rehabilitation personnel, it w ould not constitute a skilled service, even though such services are obviously necessary.
(Medicare Benefit Policy Manual)
 The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation to support the need for skilled nursing or skilled rehabilitation personnel.  Although the a ct of turning a patient normally is not a skilled service, for some patients the skills of a nurse may be necessary to assure proper body alignment in order to avoid contractures and deformities.  In all such cases, the reasons why skilled nursing or skill ed rehabilitation personnel are essential must be documented in the patients record.   30.2.2.1  Documentation to Support Skilled Care Determinations  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether    Skilled involvement is required in order for the services in question to be furnished safely and effectively; and    The services themselves are, in fact, reasonable and necessary for the treatment of a patients illness or injury, i.e., are  consistent with the nature and severity of the individuals illness or injury, the individuals particular medical needs, and accepted standards of medical practice.  The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.
(Medicare Benefit Policy Manual)
Such determinations would be made from the perspective of the patients condition when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury.  Thus, when a service appears reasonable  and necessary from that perspective, it would not then be appropriate to deny the service retrospectively merely because the goals of treatment have not yet been achieved.  However, if it becomes apparent at some point that the goal set for the patient is  no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.  By the same token, the treatment goal itself  cannot be modified retrospectively, e.g., when it becomes apparent that the initial treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initi al goal of treatment from restoration to maintenance.  Instead, it would make such a change on a prospective basis only.  Although the presence of appropriate documentation is not, in and of itself, an element of the definition of a skilled service, such documentation serves as the means by which a provider would be able to establish and an A/B MAC (A) would be able to confirm that skilled care is, in fact, needed and received in a given case.   It is expected that the documentation in the patients medical record will reflect the need for the skilled services provided.  The patients medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed.  Taken as a whole, then, the documentation in the patients medical record should illustrate the degree to which the patient is accomplishing t he goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.