The 30-day window is in place to allow a beneficiary access to remaining skilled days after a period at a non-skilled level without requiring another 3-day qualifying hospital stay.  In order to re-access benefits, a patient's new condition must be related to a condition or problem for which care was originally provided during the 3-day hospital stay or during the SNF stay following the 3-day hospital stay.  Source: Medicare Benefit Policy Manual, Chapter 8, Section 20.1.

Continued assessment of skilled needs for patients within their 30-day window can be a challenge.  It is critical that facility staff have an understanding of this process in order to communicate changes in patient status for the Medicare team to review.  
 
The specific condition or problem may be the reason for admission or one related to another chronic condition.  For example, a patient admitted to the hospital with pneumonia and who has a diagnosis of Multiple Sclerosis, receives care at the hospital for both pneumonia and Multiple Sclerosis.
 
Having a familiarity with the patient may lead to the conclusion that the patient has returned to baseline or that this condition is not expected to change.  Exacerbation of chronic conditions may meet the skilled level of care criteria despite the fact that the patient has had these issues in the past (e.g. recurrent exacerbation of COPD or CHF).  The patient is considered skilled, if a skilled level of care is rendered and coverage conditions are met, regardless of prior functional or clinical status.
 
The following scenarios should trigger a review for a potential return to a skilled level of care:

• Indication of daily or more frequent assessment of vital signs, description of lung or bowel sounds and skin conditions, deficiencies in nutritional status and hydration, mental status and mobility related to the instability or probable changes in condition.
• Documented changes in the patient's vital signs, nutritional status, skin condition, etc. that reflect "instability".  Lack of changes in physical condition does not, in and of itself, preclude the need for observation and assessment.  Documentation must support that there is a reasonable probability for changes in the patient's condition;
• Repeated modifications in the treatment plan as a result of changes in the patient's condition.
• Onset of a new condition, diagnosis or problem that requires nursing assessment, monitoring or interventions.
• Therapy evaluation and or treatment at any frequency.
• Order changes resulting in a change in the plan of care or treatment regimen.
• Emergency room visits or physician consults.
• Weight loss.
• Changes in skin integrity.

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