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Q: If a Medicare Part A resident exhausted benefits for a skilled PEG tube, is a 60-day wellness stay outside of a nursing facility (like at home) required in order to replenish their 100 days?
A: It has to do with the benefit period - if the resident uses their 100 days, but is still receiving their skilled service (G-tube) - the resident is still receiving skilled services, but Medicare will not be paying for it. For a resident to qualify for another benefit period they have to not receive skilled services for the 60-day wellness break. For someone dependent on tube feedings, they may never have a 60-day break in skilled services. The only way would be to have the tube taken care of by the resident or family member at their home - somewhere outside of the SNF or if the amount of nutrition received by the tube falls below the intake requirements for a tube while they are in the facility. As you know, some residents will depend on nutrition via the tube for a very long period of time - and thus not get a 60-day break in those skilled services.
Per the Medicare Benefit Policy Manual, Chapter 8, a feeding tube is considered a direct daily skilled service when these quantity requirements are met: “Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day”
The RUG-IV classification requirements for Tube feeding include: (1) K0710A3 is 51% or more of total calories OR (2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days.
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