Skilled Nursing Facility Qualifying Inpatient Stay

6.1.1 - Skilled Nursing Facility Qualifying Inpatient Stay (Rev. 924; Issued: 11-15-19; Effective: 10-01-19; Implementation: 12-17-19) Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are presumed 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 (commonly referred to as the “5-day” assessment) prescribed in 42 CFR 413.343(b), when correctly assigned to one of the more intensive case-mix classifiers that is designated (in the annual publication of Federal prospective payment rates described in 42 CFR 413.345) as representing the required level of care. 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. For a further explanation of the administrative presumption of coverage, please refer to §6.1.4 of this chapter, and to Pub. 100-02, Medicare Benefit Policy Manual, chapter 8, §30.1 (including item 3 of that section for a discussion of a rehospitalization that exceeds the 3-day interruption window specified under the SNF PPS’s interrupted stay policy). Medicare contractors shall: • Use the Common Working File (CWF) to validate the presence of an inpatient hospital claim that was paid by Medicare. Because the entire medical record from the inpatient hospital stay is not received for a SNF claim, it is difficult to determine if the medical record and the CWF conflict. Therefore, it is assumed that the dates of service for the inpatient hospital claim in CWF are correct for purposes of establishing the 3-day prior inpatient hospital claim dates. If the CWF is silent as to an associated 3-day inpatient hospital claim, confirm that the beneficiary had a 3-day inpatient hospitalization outside the Medicare system (for example, the Veteran’s Administration hospital system). If such is the case, the medical record from the inpatient hospitalization can be used to establish inpatient hospitalization dates. This documentation need not be signed for this purpose. • Presume medical necessity of the qualifying inpatient hospitalization. If, during the normal claims review process, evidence that the hospitalization may not have been medically necessary emerges, the Medicare contractors shall fully develop the case in accordance with the directions contained in Pub. 100-02, chapter 8, § 20 and 20.1. • Verify that the extended care services were for an ongoing condition that was also present during the prior hospital stay (even if not the main reason for that stay), or for a new condition that arose while the beneficiary was receiving treatment in the SNF for the ongoing condition. In this context, the ongoing condition need not have been the principal diagnosis that actually precipitated the beneficiary’s admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay. The Medicare contractors may use a hospital discharge summary or any additional documentation from the inpatient hospital to make this verification. This documentation need not be signed for this purpose.