Medicare Part A

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Introduction

Hospital insurance.

Coverage:

  • Eligibility:
  • must meet eligibility criteria
  • 3 day stay in acute hospital for stay in SNF[4]
    • SNF stay must be needed for
      • a condition treated during the qualifying hospital stay, or
      • a condition that arose in the SNF for which the patient was previously treated in a hospital
    • daily skilled care on an in-patient basis required & certified as such by an attending physician
  • home health services
  • top 26 RUGs categories automatically eligible up to assessment reference date for 1st MDS assessment;
    • afterwards, clear documentation of:
      • continuing need for skilled care
      • medical justification that the services are reasonable & necessary
  • for lowest 18 RUGs categories, eligibility can be determined on an individual basis, using established (albiet revised) administrative criteria

Deductable for part A is $1288 per benefit period (2016), i.e. 1st 60 days after an admission[2]

Acceptance & administrative functions:

  • before accepting patients, ensure they meet part A administrative eligibility criteria
  • initial assessment by nurses & therapists
  • define needs & begin treatments
  • 1st MDS done on days 5-8
    • assessment reference date = last date of observation period
    • can be transmitted up to day 31 to HCFA
  • software gives RUGs category based on MDS
    • largely based upon # of minutes of rehabilitation services during 7 day look-back period
    • these are determined by the appropriateness for each discipline based on patient's levels & goals
    • supported by patient's documentation
  • TCU unit manager, in conjunction with therapists, determine appropriate level & timing of therapies
  • 2nd MDS done on day 14
  • continual evaluation of patient's level, progress, & goals
    • adjustment of regimen

New age-friendly measure for 2025

Physicians must pay attention to:

  • part A certification requirements
  • MDS definitions
  • Federal & state requirements
  • medical necessity
  • coding requirements
  • billing requirements & documentation guidelines

What can physicians do?

  • ensure that only accurate diagnoses & ICD9 codes are listed
  • supply appropriate diagnoses & documentation to support part A coverage
  • case management
  • supply clinical input to ensure optimum MDS information
  • order only medically necessary services & document medical necessity for such services
  • act as patient advocates to ensure that all medically necessary services are provided
  • stick to the PPS formulary
  • thoroughly review all meds for appropriateness
  • make sure all documentation is consistent with nursing & other documentation on the chart
  • provide more frequent visits as required to prevent deterioration & potential ER visits
  • physician visits & order changes are important documentation to support medical observation & evaluation under the clinically complex category

More general terms

Additional terms

References

  1. Smith, R. Jewish Home for the Aging, Reseda CA, 2001, unpublished
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
    Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
    Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
    Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
    Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Medicare Benefit Policy Manual. Chapter 1 Inpatient Hospital Services Covered Under Part A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf
  4. 4.0 4.1 NEJM Knowledge+