CMS Pub. 100-02, ch. 8, § 20.2.2.3

A3-3131.3.B.3, SNF-212.3.B.3

In some cases where it is medically predictable that a patient will require a covered level

of SNF care within a predeterminable time frame, the individual may also have a need for

a covered level of SNF care within 30 days of hospital discharge. In such situations, this

need for covered SNF care does not negate further coverage at a future date even if there

is a noncovered interval of more than 30 days between the two stays, provided all other

requirements are met. (See example 1 below.) However, this rule applies only where

part of the care required involves deferred care, which was medically predictable at the

time of hospital discharge. If the deferred care is not medically predictable at the time of

hospital discharge, then coverage may not be extended to include SNF care following an

interval of more than 30 days of noncovered care (see example 2). Where it is medically

predictable that a patient will require a covered level of SNF care within a specific time

frame, the fact that an individual enters a SNF immediately upon discharge from the

hospital for noncovered care does not negate coverage at a later date, assuming the

requirements of the law are met (see example 3).

EXAMPLE 1:

A patient who has had an open reduction of a fracture of the femoral neck and has a

history of diabetes mellitus and angina pectoris is discharged from the hospital on

January 30, 1991 and admitted immediately to a SNF. He requires, among other services,

careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise

program to preserve muscle tone and body condition, and observation to detect signs of

deterioration in his condition or complications resulting from his restricted mobility,

which necessitates skilled management of his care to ensure his safety and recovery. It is

medically predictable that when he is medically allowed to bear weight on the affected

limb, skilled rehabilitative services will be required. After he is in the SNF for two days,

he becomes unhappy and at his request is released to his home in the care of a full time

private duty nurse. Five weeks later, when he reaches weight bearing, he is readmitted to

the SNF for the needed rehabilitative care. The patient would be eligible for coverage

under the program for the care furnished him during both of these stays.

EXAMPLE 2:

An individual is admitted to a SNF for daily skilled rehabilitative care that, as a practical

matter, can be provided only on an inpatient basis in a SNF. After three weeks, the

therapy is discontinued because the patient’s condition has stabilized and daily skilled

services are no longer required. Six weeks later, however, as a result of an unexpected

change in the patient’s condition, daily skilled services are again required. Since the

second period of treatment did not constitute care which was predictable at the time of

hospital discharge and thus could not be considered as care which was deferred until

medically appropriate, it would not represent an exception to the 30-day exception rule.

Therefore, since more than 30 days of noncovered care had elapsed between the last

period of covered care and the reinstitution of skilled services, payment could not be

made under the extended care benefit for the latter services.

EXAMPLE 3:

A patient whose right leg was amputated was discharged from the hospital and admitted

directly to a SNF on January 30, 1991. Although upon admission to the SNF the patient

required help with meeting his activities of daily living, he did not require daily skilled

care. Subsequently, however, after the stump had healed, daily skilled rehabilitative

services designed to enable him to use a prosthesis were required. Since at the time of

the patient’s discharge from the hospital it was medically predictable that covered SNF

care would be required at a predeterminable time interval, and since such care was

initiated when appropriate, the patient would be entitled to extended care benefits for the

period during which such care was provided.