Regulations

Ask the expert: PEG tube coverage

Q: Can a resident who has had a PEG tube in place at home, with a valid 3-day hospital stay and covered for skilled services, have an EOT and continue her coverage for a PEG tube?

This resident is receiving 26% calories and 501cc fluid via tube. Would the fact that she has had the PEG at home preclude her from receiving her 100 days in a SNF if she meets the other technical criteria?

A: As long as the resident has been home for at least 60 days without a hospitalization, meets the admission requirements (3-day qualifying stay, etc), and meets the skilled coverage requirements, then the resident is entitled to their skilled benefit. In your example, the patient had been receiving skilled therapy under Medicare Part A and then the therapy ended. If the resident has any other skilled care issues (i.e., skilled tube feeding, Stage III pressure ulcer, diabetic foot ulcer, etc), then the skilled care is ongoing and the Medicare Part A stay continues, dependent on appropriate documentation. The fact that the problem condition existed prior to the hospital stay is not a factor in the coverage.

 

Reference: IOM 100-02 Medicare Benefits Policy Manual, Ch 8, §§ 20 and 30.