Policy No: 111
Originally Created: 06/01/2009
Last Reviewed: 07/01/2019
Last Revised: 07/01/2019
This policy applies to all hospitals.
An inpatient stay which occurs within forty-eight (48) hours of discharge from the same hospital, or as defined in the Hospital/Provider Contract.
Readmission is classified as subsequent acute care inpatient admission of the same patient within 48 hours of discharge of the initial inpatient acute care admission.
Planned readmission or leave of absence
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.
Readmission to the same hospital (assigned provider identifier by our health plan) for the same, similar or related condition, is considered to be a continuation of initial treatment. Our health plan will not reimburse or permit a facility to retain reimbursement for the readmission. The two hospital admissions will be consolidated into one with all necessary codes, billed charges and length of stay combined. The maximum allowable for the consolidated stay will be recalculated using the methodology defined in the hospital contract.
This policy applies to claims processed using the Diagnosis Related Group (DRG) methodology.
Readmission to the same hospital within 48 hours of the initial admission, or as defined in the Hospital/Provider Contract, is subject to clinical review to determine if the readmission is related to or similar to the initial admission.
This policy applies to the following but not limited to:
- Clinically related readmissions
- Emergent readmissions
- Psychiatric readmissions
- Planned readmissions or leave of absence
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
Centers for Medicare & Medicaid Services (CMS) Processing Manual, Chapter 3 - Inpatient Hospital Billing, 40.2.5
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.