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M21-1, Part III, Subpart v, Chapter 6, Section D – Adjusting Compensation When a Veteran Is Hospitalized in Excess of 21 Days

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4

1.  Requesting Reports/21-Day Certificates for Admissions


Introduction

This topic contains information on requesting reports and certificates for admissions, including

Change Date

August 18, 2017

III.v.6.D.1.a.Generating and Screening CAPRI Admission Reports

Generate reports for service-connected (SC) admissions using the Admission Report for SC Veterans option available from the Compensation and Pension Record Interchange (CAPRI) Reports menu in CAPRI.
Example:
Image of the CAPRI Reports menu.
Screen each report (and associated clinical documents, if necessary) across Share to determine if the Veteran was admitted for an SC disability.
Reference:  For more information on using CAPRI, see the CAPRI User Guide.

III.v.6.D.1.b.Requesting Reports and Certificates From a Medical Facility

If a CAPRI report shows admission for treatment of an SC disability evaluated at less than 100 percent, and the Veteran remains hospitalized
  • request a
    • notice of discharge report
    • hospital summary
    • 21-day certificate, and
  • establish diary code 30, Hospitalization Report with a five year control. The note text must state, AO81 [insert disability(ies)].

III.v.6.D.1.c.  Printing 21-Day Certificates

Use the 21 Day Certificate Printing option available from the CAPRI Reports menu to generate and print new 21-day certificates from CAPRI.

Example:
Image of the CAPRI Reports menu.
Reference:  For more information on using CAPRI, see the CAPRI User Guide.

III.v.6.D.1.d.Handling an Initial Grant of SC While the Veteran Is Hospitalized

If, while hospitalized, service connection (SC) is granted with a schedular evaluation of less than 100 percent for the condition for which the Veteran is hospitalized, take action as indicated in M21-1, Part III, Subpart v, 6.D.1.b.

2.  Adjusting an Initial Compensation Award for Hospitalization


Introduction
This topic contains information on adjusting initial awards, including

Change Date

December 6, 2018

III.v.6.D.2.a.Preparing an Award Adjustment for Hospitalization

Follow the steps in the table below to prepare an open-ended Paragraph 29award.
Step
Action
1
Before preparing the open-ended Paragraph 29 award, check under the Veteran’s individual CAPRI record to verify whether the Veteran is still an inpatient or has been discharged.
2
Does the Veteran continue to be a patient?
  • If yes,
    • establish a pending EP 320 with the date of claim from the date of hospital admission, and
    • forward to the rating activity for an award ofParagraph 29 benefits.
  • If no,
3
Prominently annotate the award with “Open-end Paragraph 29 Award—21-Day Cert. dated__________.”
4
Take the EP 320 credit when the Paragraph 29 award is authorized. The date of claim should be the date of the latest Department of Veterans Affairs (VA) examination or the date of admission to the VA medical center, under the historical version of 38 CFR 3.157.

III.v.6.D.2.b.Maintaining Controls for Future Hospital Award Adjustments

To prevent overpayments, it is important to maintain tight controls for open-endedParagraph 29 awards.  To ensure such control,

III.v.6.D.2.c.Determining Commencing Date of Award

Use the table below to determine when to commence payment of an award adjustment when a Veteran is hospitalized for an SC condition in excess of 21 days.
If an award adjustment is made by reason of hospitalization for an SC condition in excess of 21 days, and the period of hospitalization …
Then …
  • starts in one calendar month, and
  • continues into the next calendar month
  • commence payment of the total rate effective the first day of the month following the date of admission, per 38 CFR 3.31(a) and 38 CFR 3.401(h)(1), and
  • reduce the award to the prehospital rate effective the earlier of the first day of the month following the month
    • hospitalization ended, or
    • treatment for the SC condition ended, per 38 CFR 3.501(m).
  • is entirely within one calendar month, and
  • a convalescent period is not required
  • commence payment effective the first day of the month of admission per 38 CFR 3.31(c)(5), and
  • reduce the award to the prehospital rate effective the first day of the following month, per 38 CFR 3.501(m).

3.  When VA Is Notified of the Discharge, Termination of Treatment, or Authorized Absence of a Veteran From a Hospital


Introduction

This topic contains information on action to take when VA receives notification of the discharge, termination of treatment, or authorized absence of a Veteran from a hospital, including

Change Date

December 6, 2018

III.v.6.D.3.a.Considering the Need for Convalescence When a Veteran Is Discharged

Use the table below to determine the appropriate actions to take when
  • a Veteran is discharged from the hospital, and
  • a period of convalescence is or is not required.
If a Veteran is discharged from the hospital and a period of convalescence …
Then …
is required
  • continue the 100-percent award pending receipt of the hospital summary
  • continue the future EP 320 control for receipt and review of the hospital summary by the rating activity
  • allow the award to continue subject to reduction effective the first day of the month following the month in which the period of convalescence ends, per 38 CFR 4.30, and
  • if a hospital summary is not received within 30 days from the date of discharge, follow up with the medical facility.
Note:  Continue the control until the hospital summary is received.
is not required
  • reduce the award to the prehospital rate effective the first day of the month following the date of discharge without referral to the rating activity
  • reinstate the prehospital evaluations
  • continue the future EP 320 control for receipt of the hospital summary, and
  • upon receipt of the hospital summary, refer the summary to the rating activity for review.
Note:  Reduction to the pre-hospitalization rate due to discontinuance of hospitalization does not require due process notification under the provisions of 38 CFR 3.105(e).
Reference:  Total disability benefits are authorized for a period of convalescence under 38 CFR 4.30.

III.v.6.D.3.b.Termination of Treatment for an SC Disability

If treatment for, or observation of, an SC disability is terminated and the Veteran remains hospitalized for treatment of a nonservice-connected (NSC) disability, the medical center notifies the regional office of the date on which treatment for this NSC disability began.
On receipt of such information, prepare an amended award effective the first day of the month following the month in which treatment for the SC disability terminated.

III.v.6.D.3.c.Consideration of Authorized Absences

An authorized absence of 96 hours or less (14 days or less for a long-term patient) does not interrupt the continuity of hospitalization when the requirements for a 100-percent evaluation under 38 CFR 4.29(a)(1) of the rating schedule are otherwise met.
One full period of authorized absence may not be immediately followed by another.  Requirements for absences exceeding these limits normally are met by releasing the patient.
If consecutive 14-day absences have been granted, a third authorized absence of 14 days is the equivalent of a hospital discharge, per 38 CFR 4.29(a)(2), unless convalescence is required.
Use the table below to determine the appropriate award action to take when a Veteran has been released or granted consecutive authorized absences.
If the Veteran has been …
Then …
released
  • with a regular discharge
  • with an irregular discharge, or
  • to outpatient treatment
reduce the award effective the first day of the month following the month of release.
Reference:  For information on release to non-bed care, see M21-1, Part III, Subpart v, 6.D.3.d.
granted three consecutive authorized absences of 14 days
  • reduce the award effective the first day of the month following the month in which the third 14-day period begins, per 38 CFR 4.29(a)(2)
  • request a hospital special report covering treatment for the SC disability that was the basis for the Paragraph 29rating, and
  • upon receipt of the report, refer the report to the rating activity.
granted an authorized absence in excess of 14 consecutive days
follow the procedures above for a third consecutive absence of 14 days.

III.v.6.D.3.d.Action Upon Release to Non-Bed Care Status

A release to non-bed care is equivalent to a regular discharge.  Apply the procedures found in M21-1, Part III, Subpart v, 6.D.3.a.

III.v.6.D.3.e.Definition:  Unauthorized Absence

An unauthorized absence is
  • the absence of a committed patient, or a patient who is considered unable to understand the significance of his/her action, from medical center or nursing home care without prior authorization, or
  • an absence that results from the failure of such a patient to return from an authorized absence
Note:  If, after 30 days, a Veteran still fails to return, he/she is either discharged or placed on non-bed care status.

III.v.6.D.3.f.Definition:  Irregular Discharge

An irregular discharge results when a patient
  • is discharged
    • against medical advice, or
    • for disciplinary reasons, or
  • fails to return from an authorized or unauthorized absence.

III.v.6.D.3.g.Actions to Take When Notified of an Unauthorized Absence or Irregular Discharge

Follow the steps in the table below when notified of an unauthorized absence or irregular discharge in a case in which a total rating is in effect under Paragraph 29of the rating schedule.
Step
Action
1
Is the Veteran competent or does he/she have a fiduciary?
  • If the Veteran is competent or has a fiduciary,
    • reduce the award to the prehospital rate effective the first day of the month following the month in which hospitalization or treatment for the SC condition terminated, and
    • process as outlined in M21-1, Part III, Subpart v, 6.D.3.a.
  • If the Veteran is not competent and does not have a fiduciary,
    • suspend the institutional award, and
    • inform the fiduciary activity of all of the facts.
2
Request a special report, explaining that a report covering treatment for the designated SC disability is required for rating purposes.
Note:  This is done regardless of the circumstances causing the termination of hospitalization.
3
Refer the special report to the rating activity to determine if
  • the prehospital evaluation should be increased, reduced, or restored, and
  • the competency status should be changed.
Notes:
  • Do not assign a convalescent rating under 38 CFR 4.29(e) of the rating schedule when termination of hospitalization was due to unauthorized absence or irregular discharge.
  • Treat a Veteran’s return following unauthorized absence of irregular discharge as a new admission. Pay Paragraph 29 benefits only after 21 consecutive days of hospitalization following return.

III.v.6.D.3.h.Adjustment for Transfer to Nursing Home Care

When a Veteran is transferred to nursing home care
  • discontinue total ratings under Paragraph 29 of the rating schedule, since the Veteran can no longer be considered to require “hospital treatment” or “hospital observation”
  • treat the date of transfer to the nursing home as the date of discharge
  • take action as outlined in Step 1 of the procedure in M21-1, Part III, Subpart v, 6.D.3.g, depending on the facts in the individual case, and
  • when the hospital discharge summary is received, refer the summary to the rating activity for appropriate rating action.

4.  Taking Action on Receipt of a Final Hospital Summary


Introduction

This topic contains information on actions to take on receipt of a final hospital summary, including

Change Date

December 6, 2018

III.v.6.D.4.a.Referring Hospital Summaries to the Rating Activity

Refer all hospital summary reports, upon receipt, to the rating activity to determine whether the prehospital evaluation should be reduced, or restored.
Reference:  For more information on convalescent ratings, see M21-1, Part IV, Subpart ii, 2.J.4.

III.v.6.D.4.b.Determining Actions When Prehospital Evaluation Is Increased or Restored

Use the table below to determine the actions to take when a prehospital evaluation is increased or restored based on receipt and adjudication of a claim for increase of a SC disability.
If a prehospital evaluation is …
Then …
increased
award the increased payment effective the day following reduction of the 100-percent evaluation, under 38 CFR 3.501(m).
Example:
Situation:
  • A Veteran was hospitalized on March 3 for an SC disability previously evaluated at 30 percent. The period of hospitalization continued until discharge on April 14. A claim for increase was received following discharge. The rating activity reviewed the hospital summary and reevaluated the disability at 50 percent effective May 1.

Result:

  • Compensation for a temporary 100-percent evaluation was assigned from March 3, with an effective pay date of April 1, under38 CFR 3.31(a).
  • Compensation for a new evaluation of 50 percent was paid effective May 1, following reduction of the temporary 100-percent evaluation.
  • restored
  • a convalescent rating is notassigned, and
  • the award was previously reduced to the prehospital evaluation
no further award action is necessary if the temporary award was already reduced as described in M21-1, Part III, Subpart v, 6.D.3. See 38 CFR 3.501(m) for the effective date of reduction of the temporary evaluation.
  • restored
  • a convalescent rating is notassigned, and
  • the 100-percent evaluation was allowed to continue
reduce payments to the prehospital rate effective the first day of the month following the month in which the period of convalescence ended.
  • restored, and
  • a convalescent rating isassigned after the temporary 100-percent evaluation was discontinued and the pre-hospitalization rate was resumed, as outlined in M21-1, Part III, Subpart v, 6.D.3.a
process an award with the convalescent rating to
  • restore the 100-percent evaluation to avoid interruption in payment at the increased amount, and
  • pay the rate for the prehospital evaluation assigned in the rating, effective the day following the last day the convalescent rate is paid.
  • process the award with the convalescent rating, and
  • take award action to effect the future change to the prehospital evaluations assigned.

 


III.v.6.D.4.c.Determining Actions When Prehospital Evaluation Is Reduced

Use the following table to determine the actions to take when a prehospital evaluation is reduced.
If a prehospital evaluation is …
Then …
  • reduced
  • a convalescent rating is notassigned
  • the 100-percent evaluation was continued, and
  • a rating proposing to reduce the prehospital evaluation per 38 CFR 3.105(e) was prepared
  • reduce payments to the prehospital rate effective the first day of the month following the month in which the period of convalescence ended
  • send the Veteran a notice of proposed adverse action, and
  • after the 60-day due process period ends, if reduction is still warranted,
    • the rating activity prepares a rating reducing the evaluation effective the last day of the month after 60 days from the date of the rating decision, and
    • the authorization activity
      • prepares the award, and
      • sends notification to the Veteran.
Note:  Provisions of 38 CFR 3.105(e) donot apply to restoration of the prehospital evaluation. However, due process notification is required for a reduction below the prehospital evaluation if it results in a reduced rate of compensation.
References:  For information on
  • reduced, and
  • a convalescent rating isassigned
  • apply the provisions of 38 CFR 3.105(e), if the prehospital rate is to be reduced following a convalescent rating, and
  • follow the procedures shown in the row directly above in this table.
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