Ask Proactive – Can you please clarify if we can skill our patient returning to the facility following a 3 day qualifying stay at a psychiatric hospital? We have a new RAI Nurse who is hesitant to skill.

Can you please clarify if we can skill our patient returning to the facility following a 3-day qualifying stay at a psychiatric hospital? We have a new RAI Nurse who is hesitant to skill.

A:

CMS speaks to skilled days following a psych stay in Chapter 8 of the Medicare Benefit Policy Manual, Section 20.1 and 30.2.3.2. According to CMS, skilling a patient for psychiatric issues  is permissible where the facility has capability to do so, but the documentation must carefully support the skilled need. Notably, this very topic has been a past focus of RAC (Recovery Audit Contractor) initiatives, reviewing SNF claims for residents admitted with a psychiatric diagnosis from psychiatric hospitals or units.

Section 20.1 – Three Day Prior Hospitalization: “While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF setting, the term “non-covered care” refers to any level of care less intensive than the SNF level of care that is covered under the program.”

Section 30.2.3.2 – Observation and Assessment of Patient’s Condition: “Skilled observation and assessment may also be required for patients whose primary condition and needs are psychiatric in nature or for patients who, in addition to their physical problems, have a secondary psychiatric diagnosis. These patients may exhibit acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior. However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs that are primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.) Therefore, these cases must be carefully documented.”