Ask the Experts

Ask the expert: Tube feeding coverage

Q: We have a lot of questions in our facility about tube feeders and Medicare Part A eligibility. Here is one example: A person getting tube fed uses 100 days of their benefit, goes off Medicare Part A, has a 60 day break in illness, and was then readmitted to hospital with a hip fracture. He is getting 100% of his caloric intake through the tube feeding. Does that person qualify for another benefit period under Medicare Part A or does the tube feeding requirement disqualify him from another Medicare Part A stay/coverage?

A: The issue here is whether the tube feeding is skilled or not. If 26% of the calories and 500 cc of fluid are going through the tube, then the tube feeding is skilled. After the 100 days of Medicare Part A benefits are exhausted, the 60 days of wellness does not begin until the tube is no longer skilled. The fact the resident went 60 days without Medicare reimbursement does not satisfy the 60 days of wellness requirement as long as he is 100% tube fed. Let’s look at a few different scenarios:

    1. The resident remains in the facility after exhausting their Medicare Part A days. The resident is still skilled for tube feeding in accordance with the guidelines, regardless of the current payer. The facility is required to send in benefit exhaust bills on a monthly basis until the resident is no longer skilled (in this case, the resident is weaned from the tube or is provided less than 26% of the calories or less than 500 cc of fluid through the tube). Assuming the resident remains skilled; the resident gets pneumonia and returns to the acute hospital for a new 3-day admission and then returns to the facility. The resident does not have a new benefit period and Medicare A will not cover the stay for the pneumonia.
    2. The resident is discharged to the community after using 100 days, whether or not he is 100% tube fed. He is not hospitalized in the next 60 days and then gets pneumonia, is admitted to the hospital for three consecutive midnights and then transferred to the SNF. Now, in all likelihood, Medicare A will cover the stay with a new benefit period since he went 60 consecutive days without a hospital stay.

The circumstances determine how you apply the rules and regulations.