Harmony is highlighting the definition of the Midnight Rule to assist facilities in determining how a patient transfer to the hospital may impact the Medicare assessment schedule.  This is a frequently asked question and there is misconception in the long term care industry as to how a facility deals with a patient who has been out of the facility less than 24 hours, but not admitted to another setting.
 
The CMS RAI Version 2.0 manual, Chapter 2 page 38 states under the heading:
 
Resident is Admitted to an Acute Care Facility and Returns:
 
"If a Medicare resident is admitted to an acute care facility and later returns to the SNF, the Medicare assessment schedule is restarted with the Medicare Readmission/Return assessment followed by the 14-Day, 30-Day, etc. A Discharge Tracking form, return anticipated and a Reentry Tracking form, would precede this."
 
"If a resident is out of the facility over a midnight, but for less than 24 hours, and is not admitted, the Medicare assessment schedule is not restarted. However, there are payment implications, since the day preceding the midnight on which the resident was absent from the facility is not a covered Part A day. This is known as the "midnight rule." The Medicare schedule must then be adjusted. The day preceding the midnight is not a covered Part A day and therefore, the Medicare assessment "clock" is adjusted by skipping that day in calculating when the next Medicare assessment is due."
 
The word "discharge" is confusing. It means two different things in the clinical and financial worlds. RAI guidelines state you must not "discharge" from the facility ("discharge return not anticipated") unless it is determined they will not return (e.g. the patient goes home, to another SNF or dies) regardless of bed hold status. There are no federal requirements as to whether a facility must create a new chart or clinically "discharge" a resident when they go to the hospital (regardless of bed hold status).
 
The MDS does not have to be done if the resident remains in observation or the ER for less than 24 hours.  It is when the resident is admitted to inpatient within 24 hours that the new MDS has to be done. The patient can be admitted to inpatient and returned less than 24 hours and this is where the facilities will have to confirm where the patient was in the hospital and if there was an admission.
 
The billing department will require instruction as the facility will not be billing for the LOA day to the Hospital.  This information must be transmitted to the FI to log this into the common working file.
 
The RAI Manual, on page 2-38 the first red bold category addresses this issue and is very clear that from a billing point of view, a provider can not bill for the day that a patient is not in the bed at midnight. Harmony recommends that facilities instruct nursing staff to record the exact time of discharge and readmission to the facility in the nursing notes. 

Do not start a new MDS schedule. A facility who chooses to start a new MDS schedule when one is not required risks loss of a RUG score that may more accurately reflect the care needs of the patient, further this action may yield a RUG score that has a lower reimbursement rate.

 
The non-billed day can be added to the patient's available skilled days if they continue to require daily skilled care which extends to 100 days.  

 

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Administrator's: A Day Dedicated to Medicare, Just for You
November 12, 2008

 

HARMONY UNIVERSITY