MDS Alert

Published on Sun Aug 14, 2005 PDF

Nail down the in's and out's of LOAs as a billing, MDS issue.

When residents go on a leave of absence, you need to know where the road forks for Medicare billing and MDS requirements - or risk having a fiscal wreck.

Watch out for "head in the bed" rule: Medicare rules allow LOAs, which can benefit the resident who attends a special family celebration or takes a trial run at home before discharge. But if the Medicare Part A SNF resident is out of the building at midnight, the SNF can't bill Part A for that day, says Maureen Wern, a consultant and president of Wern & Associates in Warren, OH.

Even so, the MDS schedule continues when the resident is out of the building on an LOA, even though the facility isn't billing the FI. Thus, facilities need to do two things to keep their billing and RUG payment on track:

1. Set up systems to ensure the facility doesn't bill for a day the resident is out of the building at midnight, suggests Christy Riekeberg, RN, C, director of subacute, rehabilitation and restorative services at Loch Haven Nursing Home in Macon, MO.

2. Try to avoid setting the assessment reference date (ARD) for an MDS while the resident is on a LOA. That way, you won't miss capturing services for obtaining the highest reimbursement, such as therapy and nursing care.

Compliance tip: You have to do the quarterly OBRA-required assessment within 92 days of each other. "So if the facility waits to do a [quarterly] assessment until the resident returns, it might miss" that deadline, cautions Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Capture What You Can

If the resident does go on an LOA during the assessment reference period, you can code MDS items that the RAI manual allows you to do, such as physician visits at P7, says Rita Roedel, MS, RN, a consultant with BDO Healthcare Group in Milwaukee.

"Make sure to collect the information based on a resident or family interview when the resident returns from the LOA," Roedel says.

Address Consolidated Billing

You don't want the resident on an LOA to go on a healthcare spree for big-ticket items such as an MRI in a freestanding imaging center that will come out of the facility's PPS pocket.

So talk to the Part A-stay Medicare resident and his family or whoever is taking the resident out for an LOA to make sure they understand the consequences (in layman's terms) of consolidated billing, advises Mines. "Instruct the resident/family or responsible person to contact the facility if the resident requires medical attention unless it's an emergency."

Assess for Significant Change

Don't forget to assess the resident for a significant change in condition when he returns from his LOA, advises Lynn Gerard, RN, director of nursing for Guardian Angels Care Center in Elk River, MN. "Look for a decline or improvement in ADLs, skin condition, weight, mood and behaviors, as examples," she advises.

The RAI manual defines a significant change as a decline or improve ment in resident status that isn't self-limited, impacts more than one area of the resident's health status - and requires interdisciplinary review or care plan revision to address. (Review when to do an SCSA in chapter 2 of the RAI manual at www.cms.hhs.gov/quality/mds20/rai1202ch2.pdf, pp. 2-7 through 2-13.)

Compliance tip: Facilities should monitor residents for [the need to do] an SCSA on an ongoing basis, emphasizes Gerard. A pattern of only doing significant change in status assessments when an MDS is due - for example, a quarterly - will raise red flags with surveyors, Gerard cautions.