Long Term Care Hospital Prospective Payment System Interrupted Stay Policy

To ensure proper billing to the Medicare Program and that you receive payment from the appropriate entity for services rendered to Medicare patients who have recently been an inpatient in a Long Term Care Hospital (LTCH), it is important to follow the LTCH three-day or less interrupted stay policy.

Interrupted Stay
An interrupted stay occurs when a patient discharges from a LTCH and, after a specific number of days, readmits to the same LTCH for further medical treatment. For example, a LTCH patient may be discharged for treatment and services that are not available in the LTCH. Each stay is evaluated separately to make certain that it meets the interrupted stay criteria. A case may have multiple interrupted stays. 

A case with interrupted stays may be eligible for other case-level adjustments (such as the high-cost outlier payment). 

The two types of interrupted stays are three-day or less interruption of stay and greater than three-day interruption of stay.

1. Three-Day or Less Interruption of Stay

For discharges and readmissions to the same LTCH within three days, the patient may:

• Receive outpatient or inpatient tests, treatment, or care at an inpatient acute care hospital, Inpatient Rehabilitation Facility (IRF), or Skilled Nursing Facility (SNF)/Swing Bed
• Have an intervening patient stay at home for up to three days without the delivery of additional tests, treatment, or care

Any test, procedure, or care provided to a LTCH patient on an outpatient basis and any inpatient treatment during the interruption is the responsibility of the LTCH under arrangements, which means that such care (including inpatient surgical care at an inpatient acute care hospital) are part of that single episode of LTCH care and bundled into the LTCH payment. 

The LTCH must pay any other providers without additional Medicare Program payment liability. If the patient receives any tests or procedures any time during the three-day interruption and the LTCH makes payment to the intervening provider under arrangements, the total day count for the patient includes all days of the interruption. 

If the patient does not receive any care during the three-day interruption, the total day count for the patient stay does not include the days away from the LTCH.

If a patient discharges to home and returns to the LTCH within three days without getting additional medical treatment, the days away from the LTCH are not included in the total length of stay (LOS); however, if the patient receives treatment on any of the three days (for which the LTCH is responsible for under arrangements), the days must be counted in the total LOS.

2. Greater than Three-Day Interruption of Stay

To meet the full definition of a greater than three-day interruption of stay, the patient must also be discharged:

• Directly from the LTCH and admitted directly to an inpatient acute care hospital, IRF, or SNF/Swing Bed
• Back to the original LTCH after a LOS that falls within the applicable fixed-day period

Although the greater than three-day interruption policy governs from the 4th day forward, the day count of the interruption begins on the first day the patient is away from the LTCH. If the interrupted stay criteria are met, the days prior to the original discharge from the LTCH are added to the number of days following readmission at the receiving facility. The days before and after an interrupted stay determine the total LOS for the episode of care.

If the patient is discharged home; the greater than three-day interruption of stay does not apply. If, however, the patient is discharged home for three days or less, the three-day or less interruption of stay applies as described above.

If the patient's stay at an inpatient acute care hospital, IRF, or SNF/swing bed falls within the fixed-day period, when the patient is readmitted to the LTCH, the entire stay is considered an interrupted stay. The LTCH receives one payment (either a full MS-LTC-DRG payment or an adjusted SSO payment, as applicable) based on the initial admission. Payment for an interrupted stay is eligible for a high-cost outlier payment, as applicable.

The inpatient acute care hospital, IRFor SNF/swing bed receives a separate payment if the greater than three-day interruption of stay policy governs the patient stay.

If the interruption in the LTCH stay exceeds the fixed-day period, the readmission to the LTCH is treated as a separate LTCH stay, and the LTCH is paid an additional payment when the patient is discharged. For example, if the patient was discharged from an LTCH to SNF and returned to the same LTCH after 47 days, the readmission is treated as a separate LTCH stay since the interruption was greater than 45 days (see chart above).

If the interrupted stay criteria are met, do not change the principal diagnosis when the patient returns to the LTCH from the receiving facility. If other medical conditions are apparent on the patient’s return, report the additional diagnosis codes on the claim. 

Not an interrupted stay
The following are not interrupted stays under the "greater than three-day interrupted stay" policy:

The patient has an LOS at the receiving facility (acute care inpatient hospital, IRF, or SNF/swing bed) that exceeds the fixed-day period. Example: Patient is discharged from the LTCH and admitted to an acute care hospital. The patient returns to the same LTCH after 10 or more days. The return to the LTCH is a new admission.

The patient is discharged to a type of facility other than an acute care inpatient hospital, an IRF, or an SNF/swing bed. Example: Patient is discharged from the LTCH and admitted to care provided by a home health care agency, then returns to the LTCH. The return to the LTCH is a new admission.

The patient is discharged to more than one facility or goes home between LTCH stays. Example: Patient is discharged from the LTCH, admitted to an IRF, then discharged from the IRF and admitted to an acute care hospital. Finally, the acute care hospital discharges the patient to the original LTCH. The return to the LTCH is a new admission.

If a stay disruption does not meet the definition for an interrupted stay, the original discharge ends the patient’s first stay. If the patient is readmitted to the LTCH, the second admission begins a new stay. The LTCH receives two LTCH PPS payments (full MS-DRG payment or adjusted SSO payment, as applicable) for two patient stays: one payment for the first stay and a separate payment for the stay after readmission to the LTCH.

If the patient’s stay meets the interrupted stay criteria, the principal diagnosis should not be changed when the patient returns to the LTCH from the receiving facility. If other medical conditions are apparent upon their return, report the additional diagnosis codes on the claim.

Currently, there are no policy provisions regarding transfers between LTCHs. The admissions to each LTCH are treated as separate cases.

Billing requirement for interrupted stay
To bill an interrupted stay, report the following on the UB-04:

• The 'from" date is the original date of admission
• The "through" date is the final date of discharge
• Payable days are reported in the Covered Days field (value code 80)
• Interruption days are reported in the Non-Covered Days field (value code 81)
• Occurrence span code (OSC) 74 with the dates the patient was absent at midnight (interruptions of more than one day)
  • OSC "from" date is the date of initial discharge from the LTCH
  • OSC "through" date is the last date the patient is not present at the LTCH at midnight
• Revenue code 018X to show the number of interruption days
   

One day interruption
When a patient is discharged from an LTCH and admitted either to an acute care hospital, IRF, or SNF/swing bed, then returns to the LTCH by midnight of the same day, it is a one-day interrupted stay. Do not report OSC 74 or revenue code 018X since the patient was not absent at midnight.

Further information is at: CMS IOM Publication 100-04, Chapter 3, Section 150 — Long Term Care Hospitals (LTCHs) PPS and 150.9.1.2 — Interrupted Stays (PDF) and Long-Term Care Hospital PPS.