Medicare ADVISOR Q&A

Medicare Advisor

Pauline Watts and Danna Mullins

Question: A patient has a physician ordered therapeutic (social) leave of absence from her Part A Medicare stay in the skilled nursing facility (SNF) that lasts for 48 hours. The patient then returns to the facility to resume skilled services (again under physician order). We are all aware of the increased potential for Medicare denial on such a patient who was able to successfully tolerate being at home for 48 hours. We are also aware that we cannot bill for any day when the patient was out of the facility at the midnight census taking. The question is, do we need to discharge the patient and readmit (and start a new five-day MDS) since the patient was gone for more than 24 hours?

We have referenced conflicting information in looking at the Medicare Manuals. The July 30, 1999 Federal Register talks about the "midnight rule" and there being no need to discharge a patient on either a medical or social leave of absence for less than 24 hours' duration. This would lead one to assume that it is unnecessary to  discharge and readmit a patient who is on either of these types of  leave of absence greater than 24 hours (but it doesn't exactly say that).

The February 2001 Final Rule Manual (page 56) identifies two separate types of "leave of absence."  "Medical" leave of absence seems to specifically require discharge/readmit if it exceeds 24 hours. "Therapeutic/Social" does not specify any time restrictions. The Final Rule manual also says that the leave of absence criteria have not changed-possibly meaning that the information from the earlier Federal Register remain pertinent. What is your opinion on this? Do we need to discharge and readmit our patient (with new five-day MDS), or can she just pick up where she left off with regard to her Medicare "clock?"

Answer: When a patient goes on a leave of absence you do not discharge the patient and then readmit on a return/readmit. The information that is in the Final Rule of July 1999 is still current. When a patient goes on a leave of absence the reason for this must be clearly identified in the medical record. Medicare says that the fiscal intermediaries must not interpret the "practical matter" so rigidly as to expect that none comply with the daily skilled requirement.

The instructions for billing the leave of absence can be found in the new CMS Internet Manual Pub.100-4 in Chapter 6, SNF Inpatient Stay, Section - Leave of Absence. In here they even give examples of a leave of absence over several weeks.

We believe that there are times when a patient needs that social leave-a family wedding, for example-that can take them out of the building for a couple of days. Also, leaves of absence can be critical to determining whether your facility can assure a safe discharge home for certain patients. So don't discharge, this only makes more work for the hard working wo(men) to do.

Centers for Medicare and Medicaid Services. (July 30, 1999). Medicare program; prospective payment system and consolidated billing for skilled nursing facilities-update; final rule and notice. Federal Register, 64(146), 41643-41683.

Centers for Medicare and Medicaid Services. (2004). Pub. 100-04 Medicare Claims Processing. Retrieved from the World Wide Web,

If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Linda Jones, ADVANCE for PTs & PTAs, 2900 Horizon Dr., King of Prussia, PA 19406; fax (610) 278-1425;

Pauline Watts and Danna Mullins are the co-founders of Encompass Education Inc., a rehabilitation education and consulting firm in Palm Harbor, FL. You may contact the authors at

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