Readmission Reviews: When to Combine

Readmissions can impact hospital finances both directly at the claims level and indirectly at the population level. Claim level impacts are usually defined by billing requirements compared to population level impacts that are often associated with quality-of-care measures like the Hospital Readmission Reduction Program (HRRP) and the hybrid hospital-wide readmission measure that is part of the Hospital Inpatient Quality Program (IQR). Ready to learn how to determine when claims should be combined following a readmission?

Billing Requirements for Readmissions:

Many payors, including Medicare, have billing requirements that address clinically related admissions. These policies require related admissions that occur within a specified period (usually up to 30 days) to be combined into a single claim.

Medicare Fee-for-Service (FFS) and Medicare Advantage plans required related admissions that occur on the same calendar day to be combined. These are referred to as readmission reviews and may have three distinct categories of outcomes:

• Same-day readmission for a related condition (the claims must be combined)
  • Patient requires follow-up care or elective surgery
  • Leave of absence, with expectation of readmission
• Same-day readmission for an unrelated condition (the claims do not need to be combined)
  • An example of unrelated conditions is the patient who was admitted for chronic obstructive pulmonary disease (COPD) and experiences a traumatic injury due to a car wreck on the way home after being discharged from the hospital. 
• Planned readmission/leave of absence as documented in the initial admission indicating a planned readmission will occur during the same episode of illness (even if it occurs on a different date than what was originally planned).
  • Situations where surgery could not be scheduled immediately
  • Specific surgical team was not available
  • Bilateral surgery was planned
  • When further treatment is indicated following diagnostic tests but cannot begin immediately

30-Day Readmission Reviews: Preventable Readmissions

Another category of readmission reviews, which are much more prevalent than one day reviews, are Quality Improvement Organization (QIO) Readmission Reviews for the Medicare FFS population and preventable readmissions by MA plans.

QIO Readmission Reviews

42 CFR 476.71(a)(8) gives QIOs responsibility over determining if hospitals have misrepresented admission or discharge information that results in unnecessary multiple admissions. For example, when the two confinements occurring within thirty-one calendar days from the date of discharge, could be related. Readmissions should be denied when:

• Medically unnecessary.
• Result from premature discharge from the same hospital.
• Result from circumvention of the Prospective Payment System by the same hospital
  • A patient is discharged, who required further testing or treatment; or was not medically stable at discharge.
  • A patient is readmitted to a hospital for care that would have been medically appropriate and could have been provided during the first admission.

Medicare Advantage Plan Preventable Readmission Reviews

Medicare Advantage (MA) plans also have Readmission Review Programs consistent with CMS guidance. The primary difference between QIO reviews and those performed by MA plans is that MA plans only perform readmission reviews when the subsequent admission is to the same facility.

To determine whether a patient’s discharge was preventable, the multiple factors will be considered including, but not limited to,

• Premature discharge
  • Discharge prior to establishing the safety or efficacy of a new treatment regimen.
• Inadequate discharge planning
  • Inadequate outpatient follow-up or treatment.
  • Failure to address rehabilitation needs.
• Clinical instability at the time of discharge (or failure to address signs and symptoms.
• Discharge to an inappropriate destination.

Partner with Brundage Group to strengthen your readmission review process. Our experts identify when admissions within 31 days should be combined into one claim—helping your organization reduce denials and stay compliant.