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Hospital Readmission Rules

Selina Posted Thu 02nd of April, 2020 18:54:40 PM
Hello, What are the Hospital Readmission guidelines? Can an initial visit be billed for the same problem within days? Details please! Thanks and Stay Well!
SuperCoder Answered Fri 03rd of April, 2020 08:10:25 AM

Hi Selina,

 

Thank you for your Question.

 

As per CMS, A patient who requires follow-up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence. Hospital readmissions are defined as the care provided from and to the same hospital/facility for related or similar conditions considering a continuation of initial treatment. A return hospitalization to an acute care hospital that follows a prior acute admission within a specified time period, which is clinically related to that prior admission.

 

There are different types of Readmission e.g.; Same-day Readmission for a related condition or Planned Readmission or Unplanned Readmission less than 31 days. Undermentioned details are considered as readmission criteria.

The readmission/ repeat admission/ subsequent admission should be occurred fewer than 31 days (or as otherwise stated by State and/or provider contract) after the initial discharge.

The readmission is for a diagnosis related to the initial admission or for the same problem.

The readmission should be in the same facility.

 

  • When a patient is readmitted in less than 31 days to a facility as part of a planned Readmission, the admissions are not considered two separate admissions. The Medical Records from the initial admission should indicate that additional work-up, treatment or surgical procedures are planned or expected for the same episode of illness, including bilateral procedures.
  • When a Readmission or procedure is expected (even if the date of Readmission is different from that initially planned), the Readmission will be treated as one claim and one episode of care combined DRG payment.
  • Readmissions for surgical interventions that are expected or planned when conservative and/or non-operative therapy have failed also qualify for the combined DRG review.
  • When the patient is ultimately discharged from the subsequent admission, the facility should submit one bill for covered days and days of leave.
  • If planned readmission or Leave of Absence is identified, payers may combine the initial and subsequent admissions into a single claim resulting in a combined DRG payment.

NOTE: If the patient had an entirely new condition that caused the new admit, then follow through with a whole new H&P work-up and bill the initial hospital visit.

 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf

 

Hope that Helps!

 

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