August 9, 2023

Top Questions from the Bed Management Webinar

Looking for more information about Bed Management? BESLER’s Senior Reimbursement Consultant Tim Powell answers your questions from the recent webinar.

To watch Tim’s Bed Management Webinar, click HERE.

Are designated observation units licensed by the state? If not, how do you document?

It is up to the hospital to designate observation only units. You document with an internal memo. Be careful that patients in these beds are not admitted as inpatients or billed as inpatients from the date of your designation.
Can any psych exempt unit/hospital be reimbursement for IME if they have a cap? If you did not have an exempt unit in the cap base year, can you establish one later?

First, please note that reimbursement for Direct Graduate Medical Education includes exempt units and whether of not you have an exempt unit has no impact on DGME Reimbursement. For IME, the cap is based on overall IME rules and the fact that residents are working in an exempt unit impacts the reimbursement but not the method of computing the cap. That being said for cost reporting periods beginning on or after July 1, 2023, a hospital may receive an increase in its otherwise applicable FTE resident cap (as determined by CMS) if the hospital meets the requirements and qualifying criteria under section 1886(h)(9) of the Act and if the hospital submits an application to CMS within the timeframe specified by CMS.
Are bed days required to be reported for outpatients (police drop off), but we can’t let the patient go or for infusions, but can’t leave as they have a port and are a drug abuser? Also, there are inpatients where we can not discharge due to guardianship or homeless (too hot/cold outside).

Yes, you have to report those days, but consider setting up observation only beds. Custodial care beds, for patients no longer requiring an acute level of treatment can be removed from the count of available beds if they are designated and only used for custodial care.
For the NICU, you mentioned step up newborn. Are we not required to count the bed if they receive less than intensive level of care (i.e. intermediate, convalescent just above keeping them with their mother, or custodial – i.e. adoption)?

A bed means an adult bed, pediatric bed, portion of inpatient labor/delivery/postpartum (LDP) room (also referred to as birthing room) bed when used for services other than labor and delivery, or newborn ICU bed (excluding newborn bassinets) maintained in a patient care area for lodging patients in acute, long-term, or domiciliary areas of the hospital. Beds in post-anesthesia, post-operative recovery rooms, outpatient areas, emergency rooms, ancillary departments (however, see exception for labor and delivery department), nurses’ and other staff residences, and other such areas that are regularly maintained and utilized for only a portion of the stay of patients (primarily for special procedures or not for inpatient lodging) are not termed a bed for these purposes. (See CMS Pub. 15-1, chapter 22, §2205.)
Can you guide me to where there is a list bed types of considered unavailable for Medicare?

42 CFR § 412.105
Other Excluded Beds, Beds in excluded distinct part hospital units; Beds otherwise countable under this section used for outpatient observation services, skilled nursing swing-bed services, or inpatient hospice services. Beds or bassinets in the healthy newborn nursery; and Custodial care beds.
Does CMS has any thresholds for what they consider is “insufficient staffing”? How many A&P beds per nurse?

The staffing requirements are based on state, not federal licensing requirements
For staffing availability, a lot of hospitals are able to use nursing staff from contractors when needed. So, we should not take verbatim nursing stating staffing issues, correct?

That is true and it is up to you and your staff. You should work closely with your nursing staff to prevent misunderstandings and audit adjustments.
For the 24 hour rule, just want to make sure I understand…a bed that can’t be made available in 24 hours for a minimum 30 consecutive days. Is that correct?

Beds in a unit or ward that is otherwise occupied (to provide a level of care that would be payable under the acute care hospital inpatient prospective payment system) that could not be made available for inpatient occupancy within 24 hours for 30 consecutive days; 42 CFR § 412.105.
If we offer hospice through a local company and do not have a separate & distinct hospice unit, can we carve out a pro-rated available bed days for the hospice volume?

Yes, you report the number of hospice days on Worksheet S-3 lines 24 or 24.01. We recommend having designated hospice beds.
Is it 90 days or preceding 3 months?

“Beds in a unit or ward that is not occupied to provide a level of care that would be payable under the acute care hospital inpatient prospective payment system at any time during the 3 preceding months (the beds in the unit or ward are to be excluded from the determination of available bed days during the current month);” 42 CFR § 412.105.
Is there a waiting period for O2 hook up removal before bed days can be removed?

No.
If the bed goes out of service on April 15th, does it come out of the count on June 13th (90 days) or July 1st (3 preceding months)?

Yes, that is the regulation. 42 CFR 412.105(b)(1) states: “Beds in a unit or ward that is not occupied to provide a level of care that would be payable under the acute care hospital inpatient prospective payment system at any time during the 3 preceding months (the beds in the unit or ward are to be excluded from the determination of available bed days during the current month).”
MACs have had varying rules as to what constitutes “available beds”?

We realize that and the result can be the filing of appeals. Sadly, individual auditors and supervisors can make inconsistent findings.
Are census reports allowed to prove beds were not occupied/staffed?

Census reports do not normally provide the support required. Midnight census reports are often useful in applying Medicare regulations.
Can you differentiate between Hospice and Palliative Care beds?

While hospice care and palliative care have the same meaning, hospice days are days that patients enrolled in hospice care and billed to the hospice provider.
Revisiting that Designated Hospice Unit that is managed through contract, do those beds and days need to be reported on S-3, or are they considered out of service since the hospital is not “managing” them?

If the beds are in a designated unit, they are reported on line 24. If not in a designated unit, report them on line 24.01.
When you say available beds can be restricted for staffing, how frequently can your number change for reporting on your MCR? I get that you can’t use your daily census, but I get notices every morning telling me we have x number of beds being blocked due to staffing. I have always thought that was not enough reason to alter the available beds because likely the next day those beds could be open again. Am I mistaken? If we have solid documentation of those blocked beds, can we reduce our current available bed count by those blocked beds and re-average for the year?

While it is a weighted average number of available days, to remove them from the count used for available bed days, you have to meet the 30-day and 90-day rules.
Where would we find our occupancy rate/percent?

From your Medicare Cost Report, divide line 14 column 8 by Line 14 column 2 on Worksheet S-3 Part I.