Can anyone educate me about Medicare skilled patients in a skilled nursing /longterm care facility and going out with family for a few hours or the day? I've been told that it's not suppose to happen because if they are well enough to be going out then then they no longer need skilled services and Medicare may decide to stop payment. I had a family member ask me how is Medicare going to find out? How will a routine order for LOA's with responsible party affect payment or will it? Is there a limit to LOA's and how should the order be written and should an order be obtained for a therapeutic LOA each time they want to go out. I've been given contradictory info by others. Thanks.

This is from the Medicare Benefit Policy Manual Chapter 8

Coverage of Extended Care (SNF) Services Under Hospital Insurance

http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf p35, last paragraph

"The "practical matter" criterion should never be interpreted 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 a SNF level of care find that they are unable to leave the facility, 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, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. Where frequent or prolonged periods away from the SNF become possible, the intermediary may question whether the patient's care can, as a practical matter, only be furnished on an inpatient basis in a SNF. Decisions in these cases should be based 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."

Billing:

If resident is not in facility on the midnight of LOA, Medicare cannot be billed for that day, nor the day of LOA be deducted from resident's Medicare benefit days. The patient can be billed for that LOA if prior agreement between facility and patient has been made. If there is no prior agreement, the facility will shoulder the cost for that day.

This is from a Fiscal Intermediary:

LOA Special Billing Instructions:

* Regular billing cycle (month)

* LOA days indicated as noncovered days

* 74 occurrence span code with dates patient was on LOA

* 018X revenue code with the appropriate number of LOA days and both charges fields (total

and noncovered) left BLANK.

* 0022 revenue codes with HIPPS codes (as applicable)

* Accommodation revenue code(s) and charges, not including LOA days

As seen in the special billing instructions above, LOA days are treated as noncovered days, but noncovered charges do not appear on the claim.

any skilled unit i have worked the limit is 4 hours. the facility is responsible for keeping up with the patients and knowing where they are at all times. they must sign in and out to leave the building. no facility i worked at would make a loa a issue unless the patient was out all day or over night. i had a patent once that was out for one night (when he said he would only be out 4 hours) he had to be re-admitted to the facility . most facilities will follow medicare's rules when it comes to things like this cause that is funding they don't want taken away.

This is not to dispute a facility's practice.

CMS does not emphasize a specific number of hours wherein a Leave of Absence can take place. All Fiscal Intermediaries abide by the same CMS regulation mentioned above. A facility may not impose their own strict limit on the number of hours wherein resident can be out on an LOA.

Overnight LOA does not require a resident to be discharged. Discharging and readmitting resident during an LOA seems to be a waste of staff time when all is needed is a simple billing adjustment.

It would be best to consult your FI in this situation.