Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)
Home » Total Leave Days - Medicare Only

Release Notes:
Data Element
Version 2020A

Name:Total Leave Days - Medicare Only
Collected For: HBIPS-2, HBIPS-3
Definition:Total leave days-Medicare only is the aggregate number of leave days for Medicare patients during the month. A leave day-Medicare only is defined as an authorized or unauthorized absence of a Medicare patient from a psychiatric care setting, excluding discharges, during which the patient is absent from the psychiatric care setting at the time of the daily census and is not under the direct supervision of psychiatric care setting staff while absent.

This data element is used to calculate the Initial Patient Population Size —Medicare Only data element and the denominator for HBIPS-2 and 3. ORYX vendors can refer to the Joint Commission's ORYX Technical Implementation Guide for more information.
Question:What is the sum of the number of days each Medicare patient was absent from the facility?
Occurs:5 (Overall rate and once per sub-strata)
Allowable Values:


Programming Note: The value of the Total Leave Days-Medicare Only may be determined electronically using a source such as an Electronic Record (EHR/EMR) or hospital billing system. Hospitals must document the specific data source (field and application) that is used and make this information available to their vendor. This information must be made available to The Joint Commission upon request.
Notes for Abstraction:
  • If Medicare is listed as the primary, secondary, tertiary, or even lower down on the list of payers, the patient should be counted in the Medicare inpatient days.
  • If the patient is an Undocumented Alien or Illegal immigrant, the patient should be counted in the Medicare inpatient days: Section 1011 of the Medicare Modernization Act of 2003 allows for reimbursement for services rendered to patients who are: Undocumented or illegal aliens (immigrants), Aliens who have been paroled a United States port of entry and Mexican citizens to enter the United States on a laser visa.
Suggested Data Sources:
  • Nursing notes
  • Progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Therapeutic pass None

Total Leave Days - Medicare Only
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Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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