Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Hospital Readmissions

Policy #:

MA00.023c

Policy

This policy applies to participating hospitals and hospital health systems reimbursed based on DRG/case rate methodologies. The policy does not apply to participating hospitals and hospital health systems reimbursed on a per diem basis. The policy does not apply to non-participating hospitals and hospital health systems.

READMISSION WITHIN 30 DAYS OF INPATIENT DISCHARGE

Acute care hospital stays (i.e., both inpatient and observation stays) to the same acute care hospital, or an acute care hospital within the same health system, within 30 days of discharge from the previous inpatient stay and/or for a condition related to the original inpatient stay (e.g., the same major diagnostic category [MDC], a post-operative infection, sepsis, or complication diagnosis), are not eligible for separate reimbursement when each hospital stay is paid per DRG or case rate. 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 all acute care hospital stays as a single clinical event. The claim with the higher payment will remain in place, and the claim(s) for the other related stays(s) will be retracted post payment.

CLAIM RETRACTIONS

Claim retractions will occur based on a retrospective claim audit review. Hospitals will be notified prior to any retrospective claim retraction and will 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 subsequent stays (e.g., readmission) for a condition directly related to the delivery, such as infection, post C-section ileus or other C-section or vaginal delivery complications

Planned elective hospital stays (e.g., chemotherapy)

Transplant services

Acute care transfers from one institution to another within the same health system

A condition unrelated to the original inpatient stay

Discharge from the hospital against medical advice

Behavioral health, psychiatric, and/or drug and alcohol hospital stays

Acute physical rehabilitation

REQUIRED DOCUMENTATION

At the request of the Company or one of its affiliates, the hospital(s) must submit medical records and supporting documentation pertaining to the original inpatient stay and subsequent stay(s). Medical records requested must include the following information:

Admission and discharge summaries

Physician orders

Emergency room records

Progress notes

Nurse notes

Laboratory and diagnostic testing reports

History and physical

Guidelines

The Company’s reimbursement policy for hospital readmissions will be reviewed on an ongoing basis. This review may result in changes to the current policy application (e.g., 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. Historically, nearly 20% of all hospital discharges have had a readmission within 30 days.

READMISSION WITHIN 30 DAYS OF INPATIENT DISCHARGE

Readmission within 30 days of discharge, for the purposes of this policy, is an unplanned acute care inpatient admission or observation stay at an acute care hospital within 30 days of the previous inpatient stay for a condition related to the original inpatient stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis).

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

Observation stays are acute care hospital stays for observation services. Observation services are considered an outpatient service and involve the use of a hospital bed with periodic monitoring by nursing or ancillary staff to evaluate and treat an individual’s condition or to determine the need for a possible inpatient admission.

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

References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 3: Inpatient Hospital Billing. §40: Billing Coverage and Utilization Rules for PPS and Non-PPS Hospitals, p. 91. [CMS Web site]. 08/14/25. Available at: http://www.cms.gov/manuals/downloads/clm104c03.pdf. Accessed February 27, 2026.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Acute Care Hospital Inpatient Prospective Payment. [CMS Web site]. January 2026. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html. Accessed February 27, 2026.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.023c:

05/01/2026

This version of the policy will become effective 05/01/2026.

Policy number MA00.023c has been updated to communicate the Company's revised reimbursement position to include observation stays within 30 days of inpatient discharge for a related condition as not eligible for separate reimbursement.

Revisions From MA00.023b:

08/07/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

07/01/2022

This version of the policy will become effective 07/01/2022. This policy has been updated to communicate the Company's revised reimbursement criteria for inpatient readmissions with 6-30 days.

Criteria for readmissions within five days and readmissions within 6-30 days has been revised to readmissions within 30-days of discharge to the same inpatient acute care hospital, or inpatient acute care hospital within the same health system, from the previous inpatient stay and/or for a condition related to the original inpatient stay (e.g., same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis), 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.

The following exception to the inpatient readmission rule has been added to the policy:

Planned Elective Readmissions

Revisions From MA00.023a:

11/17/2021

This policy has been reissued in accordance with the Company's annual review process.

11/20/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Inpatient Hospital Readmission.
01/15/2017	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.

Revisions From MA00.023:

01/01/2015

This is a new policy.

Version Effective Date:

5/1/2026

Version Issued Date: