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Medicare requires a 3 day hospital stay, before qualifying

Resolved Question:

Medicare requires a 3 day hospital stay, before qualifying to be moved to a nursing home and cover 100% of the nursing home first 20 days. What specific parameters, or conditions does medicare use as a qualifying 3 day hospital stay?
Submitted: 4 years ago.
Category: Health
Expert:  Dr. Mark replied 4 years ago.
1. The hospital stay from admission to discharge has to be three days (not just the time within the hospital itself, e.g. waiting in the emergency room doesn't count). The day of admission is day 1, but the day of discharge does not count, so you have to get to three days, not including the day of discharge.

2. The hospital stay must be medically necessary (obviously).

3. The medical condition causing the hospital stay must be the reason for treatment and need for extended care.

for the actual wording, see page 7 of this:
http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf


20.1 - Three-Day Prior Hospitalization
Customer: replied 4 years ago.
Doctor Mark, I need specific answers to my question. My mother is in the last stages of alheimers. I have been taking care of her for the past 6 years. She fell, and broke her hip a year ago, and although I undersand that that is one requrement, but I chose to continue my care for my mother for an additional year and a half. She takes no medicinces what so ever, When I gave her the aricept, nemanda, or any other, she would stop eating, so she is on no medicine, no diabetes, no high blood preasure. She does have a pressure ulcer ( wound in the small of her back) And it has been slowly healing, but she has had it for over 6 months. and poor circulation in the leggs, not walking. only standing to swing to the toilet. And her immune system is starting to be compromised. She has had shingles in the past 6 months, and may be getting it again. I need a specific criteria that will qualify her to be tranfered to a skilled nursing home, and for medicare to cover 100% of the first 20 days of the long term nursing care facility.
Customer: replied 4 years ago.
doctor that is just basic iformation that I all ready knew. It says nothing about the diagnosis of the patient in regards XXXXX XXXXX question.
Expert:  CamilleRN replied 4 years ago.
Hi, I aggree with Dr. Mark. I can add to this by saying that it's not so much the diagnosis as it is the documented decline in ability to perform activities of daily living. For example, if a Patient has a hip fracture and undergoes surgery, he will qualify with a 3 day hospital stay as well as his inability to walk, his diagnosis will validate physical therapy as well as skilled Nursing care and will be covered. An example of an uncovered situation would be a Patient has a gallbladder operation, and develops nausea and vomiting after surgery and is kept three days for hydration and medication. After three days she is able to get up, get dressed, walk to the cafeteria for breakfast and states she has a bit of pain with movement but is able to perform all of her own ADLS... she does not qualify...on the other hand if a patient who has gallbladder surgery can't walk or take care of himself... he would qualify. In your mother's case she would have to have something that requires the three day hospital stay to begin with. A prticularly bad case of shingles might do it, but it's unlikely. Her wound, if infected may, but also doubtful. If she were to have a sudden change in mental status, such as becomming unresponsive, or develops pneumonia, or a urinary tract infection, these things will more likely necessitate a hospital admission. Talk to her Doctor, he can get creative and help you with this. I hope this clears things up. Please click Dr. Mark's ACCEPT. Thank you:-)

Edited by CamilleRN on 2/17/2010 at 12:00 PM EST
CamilleRN, Nurse (RN)
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Customer: replied 4 years ago.
Thank you Camille! Your answer was much more informative than Dr Mark! If there is a web site that Specifically gives the criteria or parameters that medicare uses for qualifications that would be great. But the medicare manual that dr mark sent, which is the same thing that I pulled up prior to conacting you is vague, and speaks nothing of the specific requirements. If you can send me a link that is specific it would be great. Otherwise, your answer was much more informative on this issue, and thank you very much! Based on camilles answer, I accept.
Customer: replied 4 years ago.
Thank you so much Camille for answering my question. You actually took the time to type me the answer, instead of sending me a link to a general medicare manual that I all ready had. You really explained it so I could understand. I e-mailed a compliment on you. I hope that you got credit for this. if you did not get credit for it please e-mail me back. Also it was nice to know your from Daytona, I am from Daytona as well. Thanks again for your help! You can e-mail me anytime.
Expert:  CamilleRN replied 4 years ago.
Wow... we're neighbors, How about that! Thank you for the compliment and the payment, it is much appreciated. An excellent Nursing facility in the Daytona Beach area is Indigo Manor.. ( 5 star rated) the same Administration for more than 11 years. They have an excellent team that can help guide you with placement of your mother. Their phone number is(NNN) NNN-NNNN ask for Kathy or Tonya in Admissions.
Customer: replied 4 years ago.
Thank you for the info on Indigo Manor, but I Have been taking care of her for the past 6 years, and now my brother and sister have been pressuring me to bring her back up to Mass. for the last couple of years, and now pressuring me to get her up now. And I dont have a problem with that. 6 years of 24 hour care is enough for me. So I am taking my mother up to Mass. to a specific nursing home there that takes medicare as pmt. Also I have filed for her medicaid in Mass. (Masshealth). We dont have money to speak of, so it is imperative that she qualify for the first 20 days of the nursing home, or they said I would have to come up with $8,000.00 to cover the first 20 days. I am ready to fly with her, but this 3 day hospital stay has to happen first.
Expert:  CamilleRN replied 4 years ago.
Goodmorning,
I'm originally from Mass also. ( Small world, as they say! ) I commend you for taking care of your Mom for 6 years... I know how difficult this has been for you. In trying to find a way to a 3 day qualifying stay, it's important to note that there are some diagnoses that are commonly used such as 1. Failure to thrive ( nutritional deficit, some weight loss) and 2. Altered Mental status. If she has Diabetes, or COPD, or hypertension, or another disease process, an exacerbation would most likely generate a 3 day stay. Most Doctors that work with the elderly are aware of this and know various ways around it. I wish you and your Mom all the best:-)

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