April 17, 2014

Medicare Interrupted Stays Still Troublesome for IRFs

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Interrupted stays, which have been present since the outset of IRF-PPS, continue to be problematic for inpatient rehabilitation facilities (IRFs). Medicare patients who leave an IRF to receive services at another provider location and return to the IRF prior to the third midnight are subject to certain case-level adjustments based on the interruption of service at the IRF. Section 140.2.4 of the Medicare Claims Processing Manual defines interrupted stays and provides instructions for billing these claims.

What Creates an “Interrupted Stay?”

Again, when a patient is discharged from an IRF and returns to the IRF prior to midnight on the third day, the stay is classified as an “interrupted stay” for Medicare reporting and payment purposes. This is true regardless of whether the patient is discharged to home or transferred to another setting for a specific treatment or procedure. For example, if the patient experiences a significant event and is transferred back to an acute hospital bed for diagnostic procedures or treatment and then returns to the same IRF within three days, the stay still would be classified as “interrupted,” and the patient’s IRF stay would be paid under the original CMG calculated at the time of the original admission to the IRF.

If the patient leaves the IRF for services and returns before midnight on the same day, it is not considered an interrupted stay.

How Are Services That Are Provided Outside the IRF Covered?

For the patient who does not qualify as an interrupted stay – a patient who leaves the IRF, receives services elsewhere, and returns before midnight of the same day – the IRF is responsible for the provision of the services, and the alternate provider cannot bill Medicare for services provided.

For patients who leave after midnight on the first day but return before midnight of the third day, the rules for an “interrupted stay” also apply. In this case, the alternate provider should bill Medicare for the services provided, as the IRF is not responsible for payment to the provider.

If the patient does not return to the IRF prior to midnight on the third day, the case is treated as a discharge, meaning the IRF is not responsible for payment for services received after leaving the IRF.

Does an Interrupted Stay Require a New Preadmission Screen and Post-Admission Physician Evaluation?

Because Medicare considers the interrupted stay a single admission, a new preadmission assessment screening and post-admission physician evaluation are not required. The number of days the patient is absent from the IRF is not included in the IRF length of stay. However, the IRF must record the dates of the interrupted stay in the IRF-PAI document and should bill the admission as a single admission/discharge when the patient is ultimately discharged from the IRF.

Good clinical practice would dictate that updated assessments and clinical documentation include information about the reasons for the interruption, patient status at the time of return, and any required changes to the treatment plan and goals.

How is Length of Stay Calculated

The length of stay for these cases is determined by the total number of days the patient is actually in the IRF, or, more specifically, the days prior to the interruption plus the days after the interruption. The days that the patient spends in another setting during the interruption are not weighed in calculating the patient’s length of stay.

What Should IRFs Do to Ensure Compliance

When an interrupted stay occurs, the IRF should submit one claim covering the original admission through the final discharge. The claim shouldf include information related to the original stay, the readmission, and the interrupted days. The claim should include non-covered days, the occurrence span code (with “from” and “through” dates), and the revenue code for leave of absence with the appropriate number of units.

IRFs should develop the necessary controls to identify when an interrupted stay occurs and to ensure correct billing of the stay. While there is no standard control measure for this, many IRFs utilize the admissions process to ensure compliance. When a referral or a request for readmission is received, the admissions staff can verify the length of time that the patient has been absent from an IRF bed. At this point, a determination can be made as to whether the case fits the definition of an interrupted stay or if the case is actually a discharge and a subsequent new admission.

If the case is an interrupted stay, the IRF must communicate well with the business office to ensure that the claim is billed correctly, and to provide the appropriate “from” and “to” dates for submission with the claim.

If the case is a discharge and readmission, the IRF must meet all of the requirements for a new admission, including the preadmission assessment screening, the post-admission physician evaluation, and the individualized plan of care.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

Contact the Author

angela.phillips@att.net

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Angela Phillips, PT

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has 40 years of experience as a consultant, healthcare executive, hospital administrator, educator and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

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