Medicare Part A
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Introduction
Coverage:
- hospitalization
- beneficiary pays deductable of $1260
- beneficiary pays $315/day for days 61-90 of each benefit period
- beneficiary pays deductable of $1260
- skilled nursing home
- covers (in full) 1st 20 days of nursing home care after hospitalization
- covers $144/day (2016) for days 21-100 of nursing home admission provided patient requires nursing care
- patient is responsible for $185.50 per day for days 21-100 in 2021
- Medicare part A does not pay for skilled nursing facility without a qualifying hospitalization (see Eligibility below)
- covers skilled home health care for up to 60 days[2]
- nursing assessment & teaching (patient or caregiver education)
- physical therapy[2]
- speech & language therapy services
- medical monitoring (eg, vital signs, weight), wound care, medication management
- Medicare does not cover home occupational therapy, social work, or personal care home health aide services in isolation[2]
- if there is a qualifying skilled need (physical therapy, speech therapy ...), occupational therapy & a home health aide to assist with bathing is covered[2]
- does not cover home health for
- phlebotomy for laboratory testing
- phlebotomy as part of a car plan to actively manage a recently unstable medical condition is allowed[2]
- monitoring glycemic control
- home health aide[2]
- physician home visit (covered by Medicare part B)
- phlebotomy for laboratory testing
- hospice
- 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
- SNF stay must be needed for
- home health services
- must be considered home bound (3 day stay in acute hospital not required)
- face to face or telehealth visit by physician within 90 days
- need for skilled-nursing care, physical therapy or speech therapy
- home health agencies paid propectively for up to 60-day periods
- home health services for dementia if patient is unstable
- home health agencies at financial risk, thus permitted to manage case using protocols/care processes that are expected to obtain the specified outcome
- 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
- afterwards, clear documentation of:
- 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
- ↑ Smith, R. Jewish Home for the Aging, Reseda CA, 2001, unpublished
- ↑ 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 - ↑ 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
- ↑ 4.0 4.1 NEJM Knowledge+