RE: Leave of absence

[Linda Sartore]

Title: Message

A couple of past responses about LOA:   1. Yes, an LOA is fine - even if the resident wants to go out overnight.  The section copied below is from the Medicare SNF Manual (Pub 12) Chapter 2, Section 214.7, which can be found at http://cms.hhs.gov/manuals/12_snf/sn201.asp#_1_23 Please note that while it is fine for the resident to go on a LOA, the facility cannot bill for midnights that the resident is not in the bed; the MDS PPS schedule must be altered to exclude those days; and those days are not charged against the resident's benefit period days. >From the Medicare SNF Manual: "Do not interpret the "practical matter" criterion so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring an SNF level of care find that they are unable to leave the facility for even the briefest of time, the fact that a patient is granted an outside pass, or short leave of absence, for the purpose of attending a special religious service, holiday meal or family occasion, for going on a ride or for a trial visit home, is not by itself evidence that the individual no longer needs to be in a SNF to receive required skilled care. Very often special arrangements, not feasible on a daily basis, have had to be made to allow for absence from the facility. Where frequent or prolonged periods away from the SNF become possible, however, then questions as to whether the patient's care can, as a practical matter, only be furnished on an inpatient basi s in an SNF may be raised. Base decisions in these cases on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences."   2. More information clarifying PPS schedule: 41658 Federal Register / Vol. 64, No. 146 / Friday, July 30, 1999 / Rules and Regulations Final Rule III.G.3. Discharge and Leave of Absence 3. Discharge and Leave of Absence Comment: One commenter asked for a definition of ‘‘leave of absence’’ as distinguished from a ‘‘discharge.’’ Response: Although this is not a distinction that is specific to the PPS, we would like to define these terms in the context of clarifying another somewhat misunderstood aspect of Medicare coverage, the so-called ‘‘midnight rule’’ and the clinical requirements for Discharge  forms and Re-Entry Tracking forms. We received questions from other commenters on how to handle cases in which the beneficiary is out of the facility at the time of census-taking, midnight. These activities are all interrelated and have generated many questions during the initial phase of PPS implementation. There are a number of reasons why a beneficiary may leave the SNF for a ‘‘leave of absence.’’ These include a temporary home visit, a temporary therapeutic leave, or a hospital observational stay of less than 24 hours in which the beneficiary is not formally admitted to the hospital and is not discharged from the SNF. In each of these situations, there is no requirement  for the SNF to complete a Discharge or a Re-Entry Tracking form. When a beneficiary goes to an acute care hospital emergency room (ER) during his or her SNF stay and is in the ER at midnight, there is an additional aspect with regard to Medicare payment. According to Medicare rules, the day preceding the midnight on which the beneficiary was absent from the facility becomes a day for which the SNF may not bill Part A of Medicare. This is known as the ‘‘midnight rule.’’ However, for clinical purposes, as long as the beneficiary returns to the facility in less than 24 hours, was not admitted to the hospital, and was not discharged from the SNF, this time in the ER is considered a ‘‘leave of absence’’ and requires no discharge form. Likewise, from the perspective of Medicare payment under PPS, there is no requirement for any additional assessment. The day preceding the midnight is not a covered Part A day and, therefore, the Medicare assessment ‘‘clock’’ is altered by skipping that day in calculating when the next Medicare assessment is due. From a clinical standpoint, the leave of absence does not affect the ‘‘clock’’ for the clinical assessments. For example, if the beneficiary is due for his 30-day assessment on March 30 (day 30 of his Medicare covered stay), but he spends midnight of March 27 in the ER, day 30 of his Medicare Part A covered stay now falls on March 31, as March 27 does not count as one of the beneficiary’s 100 days of Medicare SNF care. In other words, the count of days in the Medicare covered stay changes when there is a noncovered day because the facility cannot count that day as one of the beneficiary’s benefit days. Given the flexibility of the assessment windows for the Medicare assessments, altering the count of days as described here should have no more than a negligible effect on assessment scheduling for facilities. Of course, a beneficiary who is required to be in the ER at midnight may well have experienced a significant change in clinical status. In that case, the facility must comply with the clinical requirement to complete a Significant Change in Status Assessment when the beneficiary returns to the SNF. The Medicare payment requirements and the midnight rule have no bearing on this requirement for completion of a Significant Change in Status Assessment. Alternatively, if the beneficiary is in the ER for more than 24 hours, or is actually admitted to the hospital or discharged from the SNF, a Discharge Tracking form is required. In addition, when the beneficiary returns to the SNF, a Re-Entry Tracking form is required, and a Return/Readmission Assessment (MDS 2.0 item A8b=5) must be performed to restart the Medicare assessment schedule. The Return Readmission Assessment fulfills the requirement for a Medicare 5-day assessment in this situation, and the next required assessment would be the Medicare 14-day assessment. Finally, with regard to MDS scheduling requirements, we are taking this opportunity to clarify the regulations text at � 413.343(b), which specifies the assessment schedule required under the SNF PPS. The current language requires the performance of such assessments on the 5th, 14th, 30th, 60th, and 90th days ‘‘following admission.’’ However, as indicated in the preceding discussion, it is not the admission date per se that determines the start of the Medicare assessment schedule, but rather, the commencement of Medicare-covered care in the SNF. Although Medicare-covered posthospital SNF care often does begin immediately upon a beneficiary’s admission to the SNF, the existing language fails to address those situations in which such care does not commence until sometime after the day of admission. The Medicare required assessment schedule is based only on those days in the Medicare Part A covered stay and, thus, cannot be scheduled based on the day of admission per se. Therefore, we are revising the language in the regulations text to take into account the possibility that a beneficiary’s ‘‘posthospital SNF care’’ (that is, SNF care that is covered under Medicare Part A) may begin subsequent to the day of his or her actual admission to the facility. The Medicare required assessments are to be performed so that, using the first day of posthospital SNF care as day 1, there is a full MDS assessment on the 5th day, the 14th day, the 30th day, the 60th day and the 90th day of the SNF stay. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Ann Schoeny Sent: Monday, April 19, 2004 11:45 AM To: [EMAIL PROTECTED] Subject: RE: Leave of absence You need to do a dischage return anticipated for 4/9/04 Then do a reentry for 4/12. Are you going to keep her skilled? If so do a medicare assessment (medicare readmission/return assessment) coded as 0/5. If she has not changed since original raps were written you can just keep her on original OBRA schedule, start a new medicare schedule. Remember that she used 6 days when figuring out when her benefit runs out. So you would do a 0/5 then 0/7(14 day) etc. Does this make sense?   ann m schoeny crnac sem haven nursing and rehab 225 cleveland ave. milford, ohio 45150 (513) 248-1270 -----Original Message----- From: Judy Lyden [mailto:[EMAIL PROTECTED] Sent: Monday, April 19, 2004 11:19 AM To: '[EMAIL PROTECTED]' Subject: Leave of absence Would anyone be able to help me?  I have a med A resident who had a temporary leave of absence to home for 3 days and then returned to the facility and I'm not understanding if I continue with the PPS schedule or need to start over.  According to the manual and information from the AANAC program manual it is sounding like a temporary leave of absence can only be for a day.  She was admitted 4-3-04 to a medicare bed.  She felt she could make it at home and went home 4-9 on bedhold and returned 4-12 because things did not go well.  We did the 5 day assessment as an admission - 5 day.  We did raps.  I understand our internal bedhold policy is separate from what we do regarding the MDS's and discharge and retracking.  However, I still have these questions:  1.  Can we just continue on with her original assessment and do a 14 day MDS with the original admission date?  2.  Do we need discharge and reentry tracking forms?  3.  Do we need a new MD cert form?   Judy Lyden, RN MDS Coordinator ext. 231