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Medicare Part A:

Get Up to Speed on Leave of Absence (LOA) Requirements

Published on Mon Nov 07, 2011

MDS experts explain what you can include on the MDS.

Don't let residents' LOAs lead your SNF's payment accuracy astray. These four pointers will help you steer clear of mistakes.

1. Know the LOAropes for COTand EOTOMRAs. "A key point related to the LOA policy is that you have to count the LOA day when counting the days of therapy delivered (or not) to determine the need to do an End of Therapy or Change of Therapy OMRA -- even though the day is not a billable day," says Marilyn Mines, RN, BSN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill.

"When a leave of absence occurs, the COT evaluation process and payment implications remain unchanged," said CMS' Penny Gershman in the agency's Nov. 3 national provider call. (See EOT and COT examples from CMS' PowerPoint slides on page 131.)

"With regard to payment ... the COT OMRA would set payment for those Medicare billable days beginning on Day 1 of the COT observation period and forward until the next scheduled or unscheduled assessment," states CMS' follow-up document for its August 23 training and Sept. 1 Open Door Forum on PPS changes. "Any days during which the resident was out on the LOA would remain non-billable to Medicare."

Real-world practice: "If a person goes on an LOA, we are counting that day for the EOT or COT OMRA," says Jim Hendricks, RN, BSN, RAC-CT, area director of clinical reimbursement at Extendicare in Milwaukee, Wis. "The bottom line is if the person goes three days [in a row] without skilled therapy, then you have to do an EOT OMRA."

2. Follow the RAImanual directions for scheduled assessments. In CMS' follow-up document, the agency states: "For scheduled assessments, pursuant to the policy outlined in Chapter 2, page 2-64, of the MDS 3.0 RAI Manual, the Medicare assessment schedule is adjusted to exclude the LOA when determining the appropriate ARD for a given assessment."

"For example, if a resident leaves a SNF at 6:00 p.m. on Wednesday, 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," states the CMS document. "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." (You can access the document at www.cms.gov/SNFPPS/Downloads/Provider_Call_FollowUp082311.pdf.)

3. Be aware of Medicare coverage criteria. "Once the person is out of the building in a hospital observation stay for more than 24 hours, a discharge assessment is required," says Ron Orth, RN, RAC-

MT, CPC, president of Clinical Reimbursement Solutions in Milwaukee, Wis. But "you don't do a discharge assessment when the person is on a social or therapeutic leave, according to the RAI manual," he adds.

Watch out: "If the person is on a one-night leave home for a holiday, that's one thing," says Orth. "But if a resident can go home for three to four days for a holiday weekend " and I'm not talking about a trial visit where you see if they can do several things " I think you have to use common sense and ask yourself whether the person really as a practical matter requires inpatient SNF services," Orth adds. "You would have to document if staff felt that the person did continue to require SNF services," he adds. "The Medicare manual does address that an LOA is not a sole reason for a denial and that the contractor will have to review the entire condition of the resident in making a coverage determination," Orth says.

4. Nail down what you can legitimately code. In Gershman's presentation for CMS' Nov. 3 national provider call, she asked this question, which is on a slide: "If a resident experiences an LOA during the observation period for an assessment, can the services provided to that resident during the LOA be coded on the MDS?" "The answer is yes," said Gershman. But "only in cases where doing so wouldn't violate any other provisions of the RAI Manual or other SNF guidelines," she added.

Example: "Mrs. S. received therapy on Monday morning but left the SNF to go to the E.R. Monday at 9:00 p.m. and returned to the SNF on Tuesday at 11:00 a.m. The therapy she received on Monday could be coded on MDS as part of the therapy look-back for the COT, with an ARD set for Thursday," said Gershman.

"You can capture services for the PPS assessment when a resident is on an LOA (whether it's a scheduled or nonscheduled PPS assessment) because the person is still considered a resident of the facility," Orth says.

If "no discharge assessment was completed, many items could be coded with supporting documentation," says Marty Pachciarz, RN, managing director of clinical services for the Polaris Group based in Tampa, Fla., who provides these examples:

  • "Falls (this could be based on resident statements);
  • A physician office visit could count as a physician visit;
  • IV/Parenteral, if it meets definitions for the purpose of hydration/nutrition;
  • Problem Conditions: Fever, vomiting, dehydration, internal bleeding, and shortness of breath;
  • Radiation or chemotherapy."

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