Inpatient Hospital Readmissions (Repeat Admissions) – Medicare Advantage

Policy No: 111
Originally Created: 08/01/2013
Section: Administrative
Last Reviewed: 07/01/2019
Last Revised: 07/01/2019
Approved: 07/03/2019
Effective: 08/01/2019
This policy applies to all hospitals.

Definitions

Readmission is classified as subsequent acute care inpatient admission of the same patient within 30 days of discharge of the initial inpatient acute care admission.

Planned Readmission or Leave of Absence is readmission according to Centers for Medicare & Medicaid (CMS) Claims Processing Manual, Chapter 3, 40.2.5.

A patient who requires follow-up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence. Hospitals may place a patient on a leave of absence when readmission is expected, and the patient does not require a hospital level of care during the interim period. Examples could include, but are not limited to, situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately. Institutional providers may not use the leave of absence billing procedure when the second admission is unexpected.

Policy statement

Readmission to the same hospital (assigned provider identifier by our health plan) within 30 days of discharge of the initial admission is subject to clinical review to determine if the readmission is related to or similar to the initial admission.

  • Readmissions occurring on the same day (or within 24 hours) will be processed as a single claim.
  • Readmissions occurring within 2 – 30 days will be subject to clinical reviews. If the clinical review indicates that the readmission is for the same or similar condition, it may be considered a continuation of the initial admission for the purposes of reimbursement.

The two Diagnosis Related Group (DRG) hospital claims will be consolidated into one, combining all necessary codes, billed charges and length of stay. The maximum allowable for the consolidated claim will be recalculated using the DRG methodology defined in the hospital contract.

This policy applies to the following but not limited to:

  • Clinically related readmissions
  • Planned readmissions or leave of absence
  • Emergent readmissions
  • Psychiatric readmissions

This policy does not apply to the following:

  • Transfer from one acute care hospital to another
  • Patient discharged from the hospital against medical advice
  • Planned readmissions for cancer chemotherapy, transfusion for chronic anemia or other similar repetitive treatments
  • Readmission for unrelated condition
  • Readmission for the medical treatment of rehabilitation care
  • Readmission for pre-delivery obstetrical care

References

Centers for Medicare & Medicaid Services (CMS) Processing Manual, Chapter 3- Inpatient Hospital Billing, 40.2.5

Chapter 4, Section 4240 (Readmission Review) of the Medicare Quality Improvement Organization (QIO) Manual.

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.