MDS Alert

Question: One of our residents went to a wedding on day 21 of her Medicare Stay and did not return to the facility until 2:00am. What happens to this day? How do we perform the Change of Therapy (COT) count?

Answer: If a Medicare resident is not in the facility at midnight, you cannot bill Medicare for that day, stated Carol Siem, MSN, RN, GNP-BC, RAC-CT in the July issue of Quality Improvement Program for Missouri’s Long-Term Care Facilities’ (QIPMO’s) MDS Tips and Clinical Pearls. So the day the resident left the facility for the wedding “will be used over again.” The day she returned would be day 21 again.

But you would handle the COT count differently, Siem cautioned. “The COT count keeps on ticking.” So if the resident left for the wedding on day five of the COT count, the day she returned will be day six.

The even bigger issue, however, is counting Medicare Part A services when a resident is not in the facility at midnight, Siem pointed out. You cannot receive payment under the prospective payment system (PPS) unless you can bill a covered day. “Also, for a non-covered day such as the day of discharge (for which no payment is possible under PPS), separate billing is not allowed for ancillary services,” she added.

Why? That’s because the PPS rates for those days you can bill already include the ancillary charges for non-billable days, Siem explained. “Ancillary charges for services furnished on the day of (but before the actual moment of) discharge are included on the SNF’s cost report and reflected in the final cost settlement.”

“As a result, even though the day of discharge itself is not a Medicare-covered day for the SNF, the PPS per diem for all of the covered days leading up to the day of discharge is somewhat higher than it otherwise would have been,” Siem said. This reflects the historical cost of these day-of-discharge services.

For more information on counting Medicare Part A services when a resident is not in the facility at midnight, go to www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf.