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Ask Diane: Does a resident ever requalify for another 100 Medicare benefit days?

Q: In regards to the 60-day spell of wellness, if a resident is in a nursing facility and utilized all 100 Medicare Part A benefit days and, due to the nature of the diagnosis, had a Gastric Peg in place, will that resident ever qualify for another 100 Medicare Part A benefit days if he or she enters into a hospital again for an entirely different diagnosis well after the 60 wellness days have elapsed?

Medicare Benefits

Some have said that as long as the tube is still in place, the resident cannot start a 60-day period wellness. But if a resident falls and fractures a hip four months later and has a three-day qualifying hospital stay, and can be skilled for therapy, nursing, etc., would the resident have Medicare Part A benefits or are they exhausted forever?

A: The definition of a skilled tube is tied to the amount of calories and percent of fluids going through the tube (26% of the calories and a minimum of 501 mls of fluid or 51% of the calories). As long as the calorie and/or percent of fluid requirements are met, the patient will not generate a new benefit period. The 60 consecutive wellness days cannot begin if the patient is receiving any skilled service. If the patient has used all 100 days, it is the responsibility of the facility to submit a benefits exhaust claim to CMS in order to prevent the common working file from generating a new benefit period. A new diagnosis does not change this scenario.