Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
With the upcoming holidays comes increased confusion related to the Medicare beneficiary’s ability to enjoy a temporary visit home to participate in holiday celebrations with his or her loved ones. While many Medicare beneficiaries are too acutely ill to leave the facility even for a brief home visit, there are no regulations preventing Medicare beneficiaries who are physically able, from enjoying a temporary home visit to participate in the holiday festivities.
According to the Medicare Benefit Policy Manual, “An outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or a trial home visit, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.”
Family members should be encouraged to communicate with staff anytime they are planning to take their loved one out of the facility for any period of time and provide as much information about the planned outing as far in advance as possible. Doing so will enable the facility to assist with making the outing a successful and enjoyable experience for all parties involved. For example, the facility staff may provide teaching and training to the patient/caregiver related to the beneficiary’s complicated medication regimen or transfer training to include car transfers. This should be included in the nursing documentation. In addition, the facility will want to provide ordered pain medications prior to the outing.
The information related to any planned outings should also be communicated to the Therapy Department as soon as the facility becomes aware of the plan. This will enable the Therapy staff to adjust the therapy schedule, if possible, to minimize the risk of missed treatments and prevent unnecessary End of Therapy (EOT) or Change of Therapy (COT) OMRAs that may result from a decrease in clinically appropriate care. Knowing in advance about an outing on Christmas Eve will allow the facility to reschedule that day's planned therapy treatments and allow the patient to continue to receive clinically appropriate therapy around the Leave of Absence (LOA) date. By adjusting the therapy schedule in this manner, the facility staff will avoid potential unexpected changes in therapy intensity that may result in a decrease in reimbursement.
Anytime a Medicare beneficiary is absent from the facility for any period of time, the documentation in the medical record should include information related to the condition at the time of departure and return. In addition, the documentation should also outline any interventions, as noted above, that the facility employed to increase the success of the outing. Lastly, the documentation should also indicate the actual time of departure from the facility and the actual return time. The actual time that the beneficiary departed and returned to the facility is important since the facility will not be reimbursed for any days in which the patient is not in the facility at midnight.
Although Medicare will not reimburse the facility for any days in which the patient is not in the facility at midnight, also known as LOA days, in the following situations it is not necessary to complete a discharge assessment or entry tracking record when the resident returns to the facility:
- Temporary home visit of at least one night; or
- Therapeutic leave of at least one night; or
- Hospital observation stay less than 24 hours and the hospital does not admit the patient
As outlined in the RAI User’s Manual in these situations the adjustment of the Medicare assessment schedule depends on whether the assessment being completed is a scheduled or unscheduled Medicare assessment.
If a resident is out of the facility for an LOA, the Medicare assessment schedule may be adjusted for certain assessments. For scheduled PPS assessments, the Medicare assessment schedule is adjusted to exclude the LOA day when determining the appropriate ARD for a given assessment.
If a resident leaves a SNF on Wednesday at 6:00 p.m., which is day 27 of the resident’s stay and returns to the SNF on Thursday at 9:00 a.m., then Wednesday becomes a non-billable day and Thursday becomes day 27 of the resident’s stay. Therefore, a facility that would choose day 27 for the ARD of their 30 day assessment would select Thursday as the ARD date rather than Wednesday, as Wednesday is no longer a billable Medicare Part A day.
In the case of unscheduled PPS assessments, the ARD of the relevant assessment is not affected by the LOA because the ARDs for unscheduled assessments are not tied directly to the Medicare assessment calendar or to a particular day of the resident’s stay. For instance, the COT observation period ends seven days following the ARD of the most recent PPS assessment used for payment, regardless if an LOA occurs at any point during the COT observation period. For example, if the ARD for a resident’s 30 day assessment was set for November 7 and the resident went to the emergency room at 11:00 p.m. on November 9th, returning on November 10th, the seventh day of the COT observation period would remain November 14th.
Moreover, a SNF may use a date outside the SNF Medicare Part A Medicare Benefit (i.e., 100 days) as the ARD for an unscheduled PPS assessment, but only in the case where the ARD for the unscheduled assessment falls on a non-billable day due to an LOA, and the resident returns to the facility from the LOA on Medicare Part A. Remember, the COT observation period ends seven days following the ARD of the most recent PPS assessment used for payment, regardless if an LOA occurs at any point during the COT observation period. Therefore, if the ARD for a resident’s 30 day assessment was set for November 7th and the resident went to the emergency room at 11:00 p.m. on November 14th, returning on November 15th, the seventh day of the COT observation period would remain November 14th for purposes of coding the COT OMRA.
Finally, there may be cases in which the SNF plans to combine a scheduled and unscheduled assessment on a given day, but then that day becomes an LOA day for the resident. In such cases, while that day may still be used as the ARD of the unscheduled assessment, this day cannot be used as the ARD of the scheduled assessment.
If the ARD for a resident’s 5 day assessment was set for May 10th and the resident went to the emergency room at 1:00 p.m. on May 17th and returned May 18th, a facility could not complete a combined 14 day/ COT OMRA with an ARD set for May 17th. Rather, while the COT OMRA could still have an ARD of May 17th, the 14 day assessment would need to have an ARD that falls on one of the resident’s Medicare Part A benefit days.
Harmony (HHI) stresses the importance of pro-actively managing therapy delivery during the holiday season in order to maintain the delivery of clinically appropriate care and ensure that the facility receives accurate reimbursement for the services provided. With the many changes to the MDS process, this management has become even more important.If you have questions about Medicare Leave of Absences, please contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.
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