Notification

Inpatient Hospital Readmission


Notification Issue Date: 12/15/2016

This version of the policy will become effective 01/15/2017.
This version has been updated to include readmission within 6-30 days of discharge.
Language and format have been updated in the Description and Policy sections.

To view the current version of this policy, see 00.01.47b Inpatient Hospital Readmission



Claim Payment Policy


Title:Inpatient Hospital Readmission

Policy #:00.01.47c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to hospitals and hospital health systems paid per case or per admission for inpatient hospital stays. The policy does not apply to inpatient hospital stays paid on a per diem basis.

READMISSION WITHIN FIVE DAYS OF DISCHARGE

Readmission to the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system, within five days of discharge from the previous inpatient hospital stay and for a condition related to the original inpatient hospital stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis), is not eligible for separate reimbursement when both inpatient hospital stays are paid per case or per admission. This will eliminate the payment of multiple case rates for a single clinical event.

For purposes of reimbursement, when the above criteria are met, the Company will treat both inpatient hospital admissions as a single clinical event. The claim with the higher payment will remain in place, and the claim for the other related admission will be retracted post payment.

MULTIPLE READMISSIONS
Multiple readmissions to the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system, within five days of the discharge from the most recent inpatient hospital stay and for a condition related to the original inpatient hospital stay, are not eligible for separate reimbursement, when each inpatient hospital stay is paid per case or per admission. This will eliminate the payment of multiple case rates for a single clinical event.

For purposes of payment (when the above criteria are met), the Company will treat all inpatient hospital admissions as single clinical events, and the claim with the highest payment will remain in place and the claims for the other related admissions will be retracted.

CLAIM RETRACTIONS
Claim retractions will occur based on a retrospective claim audit review. Hospitals will be notified prior to any retrospective claim retraction and be afforded the facility audit review process for dispute resolution. In the event the combined claims would trigger an outlier payment, the allowed amount for the paid admission will include any applicable outlier payment.


READMISSION WITHIN 6-30 DAYS OF DISCHARGE

Readmission to the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system, within 6-30 days will be subject to medical chart review to determine if the readmission was related to the original inpatient hospital stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis), and determined to be preventable or avoidable. If the medical chart review indicates that the readmission was related, preventable or avoidable, the claim representing the readmission will be retracted post payment. The following criteria will be considered during the medical chart review:
  • Acute decompensation of a coexisting chronic disease that may be related to care during the initial admission or follow up care after discharge (e.g., admission for uncontrolled diabetes after initial admission for asthma)
  • An acute medical complication or post-operative complication related to care during the initial admission or post-discharge care (e.g., urinary tract infection as a result of urinary catheter placement at the initial admission, deep venous thrombosis following surgery to repair hip fracture, post-operative wound requiring drainage following initial admission for abdominal surgery)
  • An unplanned surgery or admission to address a continuation or recurrence of the same problem as the initial admission (e.g., individual readmitted for cholecystectomy following initial admission for fever and elevated liver function tests or readmission for congestive heart failure after an initial admission for congestive heart failure)
  • A condition or procedure indicative of a failed surgical or procedural intervention (e.g., repeat admission for an endoscopic intervention for gastrointestinal bleeding)
  • A need that could have reasonably been prevented by the provision of appropriate care consistent with accepted standards in the prior discharge or during the post discharge follow up period (e.g., readmission for heart failure if individual did not have sufficient follow-up instructions to refill diuretic prescription)
  • An issue caused by a premature discharge from the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system

MULTIPLE READMISSIONS
Multiple readmissions to the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system, within 6-30 days of the discharge from the most recent inpatient hospital stay for a condition related to the original inpatient hospital stay and determined to be preventable or avoidable, are not eligible for separate reimbursement, when each inpatient hospital stay is paid per case or per admission. This will eliminate the payment of multiple case rates.

For purposes of payment (when the above criteria are met), the claim for the initial inpatient acute care hospital stay will remain in place and the claims for the other related readmissions will be retracted.

CLAIM RETRACTIONS
Claim retractions will occur based on a retrospective claim audit review and a medical chart review. Hospitals will be notified prior to any retrospective claim retraction and be afforded the facility audit review process for dispute resolution.

POLICY EXCEPTIONS

This policy does not apply to the services listed below:
  • Maternity and newborn care, with the exception of post-delivery admissions when the readmission is for a condition directly related to the delivery such as infection, post C-section ileus, or other C-section or vaginal delivery complications
  • Chemotherapy, which includes the treatment of malignant disease by chemical or biological antineoplastic agents, monoclonal antibodies, bone marrow stimulants, antiemetic agents, and other related biotech products
  • Transplant services, including organ and tissue transplantation from a live or cadaveric donor
  • Transfers from one institution to another
  • A condition unrelated to the original hospital admission
  • Individual discharged from the hospital against medical advice (for readmissions within the 6-30 days provision)
  • Behavioral Health/Psychiatric/ and or Drug and Alcohol admissions
  • Acute Physical Rehabilitation

REQUIRED DOCUMENTATION

At the request of the Company or one of its affiliates, the hospital or hospitals within a health system as applicable must submit medical records and supporting documentation pertaining to the readmission to determine whether the readmission is indirectly related to or a potentially preventable readmission. Medical records requested must include the following information:
  • Admission and discharge summaries
  • Physician’s orders
  • Emergency room records
  • Progress notes
  • Nurse’s notes
  • Laboratory and diagnostic testing
  • Patient history and physical

Documentation for determination must be submitted within 30 days of receipt of request. Failure to provide requested medical records as per the defined timeframe may result in an initial adverse determination; and denial of the claim post payment. Hospitals will be afforded the applicable facility appeal and dispute resolution process. Please refer to the Hospital Provider Manual.
Guidelines

The Company’s reimbursement policy for inpatient hospital readmissions will be reviewed on an ongoing basis. This review may result in changes to the current policy application (eg, from post-pay to pre-pay).

Description

According to the Centers for Medicare and Medicaid Services (CMS), acute care hospital readmissions may result from actions taken or omitted during a member’s initial acute care hospital stay. CMS findings in 2008 indicated that 18% of all hospital discharges result in a readmission within 30 days.

READMISSION WITHIN FIVE DAYS OF DISCHARGE

Readmission within five days of discharge, for the purposes of this policy, is an unplanned inpatient acute care hospital readmission within five days of the previous inpatient hospital stay for a condition related to the original inpatient hospital stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis).

The five day readmission provision includes the day of discharge and the following five calendar days. For example, if the individual is discharged on Monday and readmitted on Monday, Tuesday, Wednesday, Thursday, Friday, or Saturday, the five day readmission provision applies. If the individual is discharged on Monday and readmitted on Sunday (or any day thereafter), the five day readmission provision does not apply.

Multiple readmissions, under the 5 day readmission provision, are two or more unplanned inpatient acute care hospital admissions within five days of discharge from the most recent inpatient hospital date of discharge and for a condition related to the most recent inpatient hospital stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis).

READMISSION WITHIN 6-30 DAYS OF DISCHARGE

Readmission within 6-30 days of discharge, for the purposes of this policy, is an unplanned inpatient acute care hospital readmission within 6-30 days of the previous inpatient hospital stay for a condition related to the most recent inpatient hospital stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis), and determined to be preventable or avoidable.

The 6-30 day readmission provision includes the day of discharge and the following thirty calendar days.

Multiple readmissions, under the 30 day readmission provision, are two or more unplanned inpatient acute care hospital admissions within thirty days of discharge from the most recent inpatient hospital date of discharge and for a condition related to the most recent inpatient hospital stay (e.g., same major diagnostic category [MDC] post-operative infection, sepsis, or complication diagnosis), and determined to be preventable or avoidable.
References


Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 3: Inpatient Hospital Billing. 40.2.4: IPPS Transfers Between Hospitals. Part A: Transfers Between IPPS Prospective Payment Acute Care Hospitals; p.116. [CMS Web site]. 12/10/10. Available at: http://www.cms.gov/manuals/downloads/clm104c03.pdf. Accessed November 7, 2016.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Acute Care Hospital Inpatient Prospective Payment. [CMS Web site]. 12/17/10. Available at: http://www.cms.gov/MLNProducts/downloads/AcutePaymtSysfctsht.pdf. Accessed November 7, 2016.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/15/2017
Version Issued Date: 01/15/2017
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.