Midnight rule

Specialties MDS


I have worked with many MDS co-ord and BOM who did not do a 5 day or bill for Medicare pt admitted and d/c on same day, however I have recently changed jobs and the BOM bills for that day although there isn't a 5 day done, she bills default rate,. First of all there isn't a MDS done so how can she bill? This is my first month at new facility and I have had 2 pt with this scenario so I did a five day. I looked it up on CMS however gotten 2 different answers. Can anyone give their advice???


1,010 Posts

Specializes in ER CCU MICU SICU LTC/SNF.

The Midnight rule exception -

40.3.5 - Determine Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence

Generally, the day of discharge, death, or a day on which a patient begins a leave of absence, is not counted as a utilization day. (See the Medicare Benefit Policy Manual, Chapter 3, "Duration of Covered Inpatient Services.") This is true even where one of these events occurs on a patient's first day of entitlement or the first day of a provider's participation in the Medicare program. In addition, a benefit period may begin with a stay in a hospital or SNF, on that day.

The exception to the general rule of not charging a utilization day for the day of discharge, death, or day beginning a leave of absence is where the patient is admitted with the expectation that he will remain overnight but is discharged, dies, or is transferred to a nonparticipating provider or a nonparticipating distinct part of the same provider before midnight of the same day. In these instances, such a day counts as a utilization day. This exception includes the situation where the beneficiary was admitted (with the expectation that he would remain overnight) on either the first day of his entitlement or the provider's first day of participation, and on the same day he was discharged, died, or transferred to a nonparticipating provider.

RAI, p2-70

Resident Expires Before or On the Eighth Day of SNF Stay

If the beneficiary dies in the SNF or while on a leave of absence before or on the eighth day of the covered SNF stay, the provider should prepare a Medicare-required assessment as completely as possible and submit the assessment as required. If there is not a PPS MDS in the QIES ASAP system, the provider must bill the default rate for any Medicare days. The Medicare Short Stay Policy may apply (see Chapter 6, Section 6.4 for greater detail).


623 Posts

Specializes in Clinical Documentation Specialist, LTC.

In a nutshell, the BOM is billing for room and board for the time the patient was there, so the facility will get a default rate for the patient.

Please sign in to comment

You will be able to leave a comment after signing in

Sign In

By using the site, you agree with our Policies. X