Medicare Presumption of Coverage

Medicare Presumption of Coverage:  Under SNF PPS, beneficiaries who are admitted or readmitted directly to an SNF after a qualifying hospital stay are considered to meet the level of care requirements up to and including the assessment reference date for the 5-day assessment when assigned to one of the Resource Utilization Groups (RUGs) that is designated as representing the required level of care.  The coverage that arises from this Medicare presumption of coverage remains in effect for as long thereafter as it continues to be supported by the facts of the beneficiary's condition and SNF care needs. 

In general, CMS presumes that beneficiaries admitted to an SNF immediately after a hospital stay require a skilled level of care.  Therefore, CMS has developed the presumption of coverage policy.   This Medicare presumption of coverage policy applies to the Medicare stay from the date of admission to the Assessment Reference Date of the 5-day MDS.

When a beneficiary is assigned correctly into one of the top 35 RUG categories, it is believed that care provided to the beneficiary meets the skilled level of care definition.  Nonetheless, there must be supportive documentation in the clinical record addressing the needs of the beneficiary and the skilled services being rendered to the beneficiary by the facility staff.

When a beneficiary is assigned to one of the lower 18 categories, he or she is not automatically classified as meeting or not meeting the definition of skilled services.  Documentation of patient conditions, staff intervention, skilled observation, and assessment must clearly identify the qualifiers to support continued skilled coverage.

In regards to the patient described above, this patient potentially has experienced an exacerbation of UTI that was initially treated during hospitalization and during the SNF stay.  There is a high likelihood of IV administration while in the ER as a saline lock is present.  Kris B Harmony recommends collecting all available data from the ER.