Inpatient Readmissions

Description

Inpatient readmissions are defined as inpatient stays to the same hospital within 30 days that represent treatment for the same, similar, or related condition.

Blue Cross NC will not allow separate reimbursement for claims identified as an inpatient readmission.

Contractual language and exceptions will supersede this policy.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse for inpatient readmissions according to the criteria outlined in this policy. 

Reimbursement Guidelines

Inpatient Readmission

Blue Cross NC considers an inpatient stay to the same hospital for the same, similar, or related condition within 30 days from previous discharge to be an inpatient readmission. Inpatient readmissions are not separately reimbursable. Reimbursement is allowed for the original admission and should not be combined to qualify for outlier reimbursement.

Inpatient readmission criteria may include, but are not limited to:

• The same or closely related condition or procedure as the prior discharge.
• An infection or other complication of care.
• A condition or procedure indicative of a failed surgical intervention.
• An acute decompensation of a coexisting chronic disease.
• 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 followup period.
• An issue caused by a premature discharge from the same facility.

Inpatient readmission review does NOT include:

• Admissions for the medical treatment of cancer, primary psychiatric disease, transplant, and rehabilitation care
• Planned readmissions
• Member transfers from one acute care hospital to another
• Member discharged from the hospital against medical advice on initial admission

Planned Readmission / Leave of Absence

Members readmitted to a hospital as part of a planned readmission or leave of absence are not considered separate stays and must be submitted as one claim. Leave of absence days are not reimbursable.

Rationale

Consistent with Centers for Medicare, and Medicaid Services (CMS), Blue Cross NC will not separately reimburse inpatient readmissions.

This policy was developed in alignment with CMS and the National Quality Forum (NQF).

Blue Cross NC may request medical records for the initial and subsequent inpatient stays to review the clinical conditions, treatment and management and determine if the readmission criteria for the subsequent admission exists. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com. 

Related policy

n/a

References

CMS- Quality Improvement Organizational Manual Ch.4. Section 4240. https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/qio110c04.pdf

NQF: All-Cause Admissions and Readmissions (qualityforum.org) https://www.qualityforum.org/Projects/NQF_All-Cause_Readmissions_Project.aspx

History

9/30/2022 - New policy developed. Medical Director Approved. Notification on 7/26/2022 for effective date 9/30/2022. (cjw)

12/31/22 - Routine Policy Review. Minor revisions only. (cjw)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this policy.

This policy applies to facilities reimbursed for inpatient services by diagnosis-related groups (DRG) methodology.