Skip Days, the Midnight Rule, & omra’s – Managing the mds 0 Assessment Schedule

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Skip Days, the Midnight Rule, & OMRA’s – Managing the MDS 3.0 Assessment Schedule
Tracking skip days, planning regular assessment reference dates, and selecting the best RUG’s level that was medically appropriate presented difficult scheduling and accounting challenges in the past. Overlay the new COT and EOT OMRA compliance rules on top of this already complex compliance regimen and the therapists’ and MDS coordinators’ lives just got a lot more complicated! Let’s try to clarify these rules.
Skip Days & The Midnight Rule
A leave of absence day, more commonly known as a “skip” day, occurs when a patient leaves the facility before midnight, returns within 24 hours, and is not admitted to a hospital. Their assessment schedule continues uninterrupted and the day out of the facility at midnight is skipped when selecting the next scheduled assessment reference date (“ARD”) upon their return to the facility.
If the skip day occurs in a scheduled assessment period, then the treatment minutes and discipline days provided on the skip day are included in the patient’s RUG’s level calculation. However, the skip day is non-billable to Medicare and the facility receives no reimbursement for that day. The patient is not discharged from nor re-admitted to the facility on the skip day. The RUG’s level calendar is adjusted by skipping that calendar day in determining when the next ARD is due.
An example of selecting the appropriate ARD for a scheduled assessment with a skip day is as follows. The patient leaves the facility on Wednesday Day 27 in the evening and returns on Thursday morning. Wednesday is a non-billable day and Thursday now becomes Day 27. The therapist would select Thursday Day 27 for the 30 Day assessment rather than Wednesday which should no longer appear in the assessment schedule as an available calendar day.
Skip Days & Unscheduled Assessments
The ARD for the 7 day look back period for an unscheduled assessment is not affected by the skip day because the ARD’s for unscheduled assessments do not relate directly to the assessment calendar or to a particular Medicare day.
An EOT OMRA must be performed if the patient has a break in therapy services for 3 calendar days, which might include a skip day. If a patient missed therapy on Monday and Tuesday, had a skip day on Wednesday, return to the facility and received therapy on Thursday, then an EOT OMRA would be required with an ARD set for Monday, Tuesday, or Wednesday.
A COT OMRA must be performed if there is a decline in minutes provided below those established for billing purposes on the most recent ARD. The COT observation day is 7 days after the last ARD whether or not a skip day is included in the COT observation period. If a patient’s 30 Day assessment was set on November 7, a skip day occurred on November 9, and they returned to the facility on November 10, then Day 7 of the COT observation period would remain November 14. As before, skip days when the patient was out of the facility would be non-billable to Medicare.
Complex Analyses Made Easy
Therapy managers are far too busy and face too many challenges to be expected to “analyze” complex skip day rules, compute alternative scheduled assessments or 7 day look back periods based on these rules, and determine the appropriate RUG’s level each day. They require simple and effective tools to manage these complex rules so they can focus on providing high quality patient care.
CarePoint therapy management software provides therapists with easy-to-use tools that track skip days, manage scheduled and unscheduled assessment periods, and compute the highest RUG’s level that is medically appropriate.

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