Leave of Absence (LOA) and Hospital Repeat Admission Billing
Patient is placed on Leave of Absence (LOA) and readmission is expected.
Hospitals may place a patient on a LOA when readmission is expected and the patient does not require a hospital level of care during the interim period. Examples include, but are not limited to:
- Situations where surgery could not be scheduled immediately
- Specific surgical team was not available
- Bilateral surgery was planned
- When further treatment is indicated following diagnostic tests but cannot begin immediately
Note: Institutional providers should not use LOA billing procedures when the second admission is unexpected.
LOA billing for acute care Prospective Payment System (PPS) hospitals.
Placing a patient on LOA will not generate two (2) payments. Since LOA is not considered as two (2) separate admissions, the provider should only submit one (1) bill and only one (1) Diagnosis Related Group (DRG) payment will be made.
Bill using the following guidelines:
- When a patient ultimately discharges, submit one (1) bill for both covered days and days of leave
- Bill days of leave using value code 81 — Noncovered Days in (FLs 39–41)
- To account for the LOA noncovered days in the billed accommodation days/units, show noncovered days/units under revenue code 018x (LOA) with zero charges
- Use occurrence span code 74 (LOA) to report the dates the leave began and ended
Note: Providers are not permitted to charge a beneficiary for days of leave.
LOA Billing for Non-PPS Hospitals
- Submit an adjustment bill (type of bill xx7) when a patient on LOA was shown as "Still Patient" (patient status code 30) on an interim bill and either:
- Does not return within 60 days, including the day leave began; or
- Has been admitted to another institution at any time during the leave of absence
- Show the day the patient left the hospital as the date of discharge
- A beneficiary cannot be an inpatient of two facilities at the same time
- Note: Home health or outpatient services provided during the leave of absence do not affect the leave and no discharge bill is required
Patient is discharged and later readmitted for a related condition.
Hospitals should adjust an original claim generated by an original stay when a patient is discharged/ transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition. Adjust the claim by combining the original and subsequent stay onto a single claim. The admit date will be date of first admission.
If services were rendered by another entity during a combined stay, the acute care PPS hospital will be responsible for payment of those services per common Medicare practice.
Examples of related readmissions are:
- Patient requires follow-up care or elective surgery
- Leave of absence, with expectation of readmission
- Readmit to the same hospital on the same day with the same related symptoms
- Includes incidents where patient leaves against medical advice (AMA) and returns the same day to same hospital
Patient is discharged and later readmitted for an unrelated condition
When a patient is discharged/transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated to, and/or not for evaluation and management of, the prior stay’s medical condition, hospitals should bill as:
- Two separate claims — do not combine claims
- Place condition code (CC) B4 on readmission claim (FLs 18–28) to indicate services are not related
- Ensure that the claim contains an admission date equal to the prior admissions discharge date
Note: Upon the request of the Medicare Contractors, hospitals must submit medical records pertaining to the readmission.
Reference: CMS IOM, Publication 100-04, Chapter 3, Section 40.2.5 (Repeat Admissions) and 40.2.6 (Leave of Absence) (PDF, 2.6 MB).