1135 Waiver 

As we move forward utilizing waivers in our efforts to contain the spread of COVID and preserve acute care capacity, we realize our decisions and documentation will most likely be reviewed at a much later date in time. In a risk mitigation effort, we asked our VP of Medical Review and Clinical Compliance, Ashley Duggan to provide her insight towards critical elements that need to be communicated amongst the IDT as well as included in our medical records surrounding waiver of the 3-day qualifying hospital stay requirement, particularly in situations where long term care residents are being transitioned into a skilled stay.  
Given the volume of discussion surrounding waiver of the 3-day qualifying hospital stay, the following may be helpful to confirm the IDT decision to skill in place:

  • What is the resident’s skilled need?

  • What is the resident’s primary diagnosis for skilled care?

  • Which discipline is the skilling entity?

  • Are admit to skilled orders in place?

  • Is valid physician certification in place, timely signed and dated, with all fields completed, and with documentation of rationale for skilled level of care?

  • Does ARD selection allow for interviews and data gathering to complete the BIMS, PHQ9 and documentation of resident usual performance for MDS Section GG? 

  • Has IDT discussion occurred to facilitate a collaborative decision to skill?

  • If the resident is receiving rehab under Part B coverage, what is the medical necessity for transition of services to Part A coverage?

  • Has billing been involved in order to apply the DR condition code and date of admission to skilled care?

  • Does the medical record illustrate medical necessity for provision of treatment under Part A coverage?

The Point Is: Plan and collaborate prior to admission to skilled level of care to satisfy CMS requirements and capture PDPM categories for accurate reimbursement


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