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Tip of the week: Understanding basic rules of consolidated billing

Contemporary Long-Term Care Weekly, October 22, 2009

Administrators need to understand a few basic rules when dealing with the consolidated billing system. The first is the 35/18 rule. The top 35 RUG categories, which are composed of rehabilitation categories, hold the presumption of meeting the level of care for SNF reimbursement. The lower 18 are not as clear-cut for SNF reimbursement. The 7/5 rule states that residents must receive skilled nursing care seven days each week and rehabilitation services five days each week for Medicare Part A reimbursement under the skilled consolidated billing system. The midnight rule states that the facility is allowed to bill for all Medicare Part A residents who are in bed at midnight. The three-day qualifying stay says that a person who has Medicare Part A must have been admitted to a hospital and spent three consecutive nights there before he or she can receive Medicare Part A nursing home coverage. If there is a three-day qualifying stay at the hospital, there are three situations that the 30-day rule may impact:

1. The resident goes home, but is admitted to the nursing home within 30 days and is skilled, then he or she can be covered under Medicare
2. The resident is not skilled upon entry to the nursing home, but becomes skilled within 30 days of entry
3. The resident is skilled and is cut from Medicare services because he or she is no longer skilled, the facility has 30 days to reinstate Medicare

This is an excerpt from HCPro’s book, The Long-Term Care Administrator’s Field Guide, by Brian Garavaglia, PhD.

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