While facility staff rightly have been focused on the rollout of the Patient Driven Payment Model, the interrupted stay policy remains a confusing area that may not be fully understood.
As The Centers for Medicare & Medicaid Services explains, “The Interrupted Stay Policy which was effective concurrent with implementation of the Patient Driven Payment Model (PDPM), sets out criteria for determining when Medicare will treat multiple Skilled Nursing Facility (SNF) stays occurring in a single Part A benefit period as a single ‘interrupted’ stay, rather than as separate stays, for the purposes of the assessment schedule and the variable per diem payment schedule.”
An interrupted stay is defined as a SNF stay in which a resident is discharged from SNF care and subsequently resumes SNF care in the same SNF for Medicare Part A covered stay during the interruption window. The interrupted stay policy also applies to those individuals who may not have been physically discharged but whose Medicare Part A stay ended.
For further clarification, an interruption window is a three-day period that begins with the first non-covered day following a Part A-covered stay and ends at 11:59 p.m. on the third consecutive non-covered day. In other words, the resident must resume Part A covered services no later than the third calendar day after their Part A covered stay has ended.
Interrupted stay examples
To move from the theoretical to the practical, here are some examples of an interrupted stay:
- Resident on Part A goes to the hospital, is under observation overnight, and returns in less than 24 hours.
- Part A stay ends on 12/5 per local coverage determinations, resident stays in facility. Medicare Part A coverage resumes as of 12/7.
- Resident on Part A discharges to the hospital and is admitted. Resident returns to the SNF on Medicare Part A two days later.
- Resident on Part A discharges to home and is readmitted to the same SNF two days later.
- Resident on Part A elects hospice services, revokes hospice services and goes back to Medicare Part A coverage two days later.
Conversely, the following examples do not qualify as an Interrupted Stay:
- Resident on Part A goes home, returns four days later.
- Resident on Part A goes to the hospital, is admitted and returns four days later.
- Resident on Part A goes home, is readmitted to a different SNF two days later.
Under the interrupted stay policy, both the PPS assessment schedule and the variable per diem payment schedule continue from the point just prior to discharge. When the stay is not considered interrupted, both the assessment schedule and the variable per diem rate reset to Day 1, as this would be considered a new stay.
One aspect of the interrupted stay policy is understanding the impact it may have on the completion of Omnibus Budget Reconciliation Act (OBRA) and PPS discharge assessments. It is important to keep in mind, that the interrupted stay policy did NOT change the OBRA assessment requirements, including OBRA discharge assessments. An OBRA discharge assessment is still required under the following circumstances:
- Resident is discharged from the facility to a private residence;
- Resident is admitted to another care facility (e.g., hospital, another SNF, etc.);
- Resident has a hospital observation stay greater than 24 hours; or
- Resident is transferred to a Medicare/Medicaid certified bed to a non-certified bed
PPS discharge assessments should not be completed when an interrupted stay occurs since the Medicare stay is not considered to have ended; it was interrupted. Under these circumstances, the OBRA discharge assessment may still be required while the SNF PPS discharge assessment is not. This a significant departure on how PPS discharge assessments were handled under the RUGs-based system.
Failure to appropriately identify those absences that do not meet the “interrupted stay” requirements can lead to significant losses of revenue due to late or missing PPS five-day assessments. Late or missing five-day PPS assessments may result in having to bill default or provider-liable days. Conversely, completing a new five-day when one should not have been completed may result in overpayments to the SNF due to inappropriately resetting the variable per diem adjustment schedule.
SNF providers will need to ensure they have adequate and accurate tracking systems in place to identify those Medicare Part A absences that may or may not qualify as an “Interrupted Stay” as this will dictate the correct sequence of actions to take related to both discharge assessments and SNF PPS assessments. This can be accomplished by reviewing each resident’s discharge and readmission/resumption of Medicare Part A coverage each day.