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Inpatient Hospital Readmission
MA00.023b

Policy

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 30 DAYS OF DISCHARGE

Admissions to the same inpatient acute care hospital, or inpatient 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., 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.


For purposes of reimbursement, when the above criteria are met, the Company will treat ​all 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(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 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
  • Behavioral Health, Psychiatric, and/or Drug and Alcohol admissions
  • Acute Physical Rehabilitation
  • Planned Elective Readmissions


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 initial admission and readmission to determine whether the readmission is related to the original inpatient hospital stay. 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

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 (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 DISCHARGE

Readmission within 30 days of discharge, for the purposes of this policy, is an unplanned inpatient acute care hospital readmission within 30 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 30-day readmission provision includes the day of discharge and the following ​30 calendar days. 

Multiple admissions under the 30-day readmission provision consist of two or more unplanned inpatient acute care hospital admissions within 30 days of discharge from the most recent inpatient hospital date of discharge and are 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).

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]. 07/08/19. Available at: http://www.cms.gov/manuals/downloads/clm104c03.pdf. Accessed April 4, 2022.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Acute Care Hospital Inpatient Prospective Payment. [CMS Web site]. February 2019. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html. Accessed April 4, 2022.

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



Coding and Billing Requirements


Policy History

7/1/2022
7/1/2022
MA00.023
Claim Payment Policy Bulletin
Medicare Advantage
No