CurrentAnthemPolicy G-13001

Reimbursement Policy Inpatient Readmissions

Defines Anthem Wisconsin reimbursement rules for inpatient unplanned readmissions within 30 days, who is affected (facilities reimbursed under DRG methodology and members in specified programs).

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification (non-material)

Effective DateMar 25, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity requirements and support claims with proper CPT/HCPCS/revenue coding in the medical record.

SourceLink

POLICY UPDATE CHANGES

Updated policy language for clarification purposes; clarified planned versus unplanned readmissions; reorganized exclusions to provide clarity.

30 daysunplanned readmission window

1 DRGDRG reimbursed for planned readmission

DRG facilitiesapplies to

Listedexclusions

Unplanned Readmission Reimbursement Rules

Unplanned readmission reimbursement criteria

Covered when ALL of the following are met:

Readmission occurs within 30 days of discharge (unplanned readmission window).

See same-day and leave-of-absence rules below.

Readmission is for the same, similar, or a related condition, infection/complication, failed intervention, acute decompensation of a coexisting chronic disease, or a need reasonably preventable by appropriate prior care.

Clinical coding criteria and/or licensed clinical medical review determine that the subsequent admission meets the above relationship criteria to the prior discharge.

The admission is to a facility reimbursed under DRG methodology (policy applicability).

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification (non-material)

Effective DateMar 25, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity requirements and support claims with proper CPT/HCPCS/revenue coding in the medical record.

SourceLink

On This Page

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Provider Requirements and Billing Impacts

Prior Authorization

Prior authorization and medical necessity

Services must meet prior authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Use industry-standard CPT, HCPCS, and/or revenue codes on all claim submissions and ensure coding is fully supported in the medical record or office notes. Standard correct coding applies.

Use proper billing and submission guidelines and compliant codes on all claims.
Services billed must be supported in the medical record and office notes.
Standard correct coding applies.

Denial Risk

Denial / recoupment risk

The health plan does not allow separate reimbursement for unplanned readmissions for the same, similar, or related condition within the readmission window. The plan reserves the right to deny the claim or recoup and/or recover monies previously paid for claims that meet this policy's criteria.

Unplanned readmission window: up to 30 days from discharge.
Denial/recoupment may apply when the subsequent admission is for the same or closely related condition, an infection/complication of care, failed surgical intervention, acute decompensation of a chronic disease, or care issues preventable by appropriate prior care.
Readmissions on the same date of service are considered a continuation of the initial admission — submit both on a single claim.

Billing Rule

Billing and documentation

Follow billing and documentation requirements: submit both admissions on a single claim when readmissions occur on the same date of service; apply correct CPT/HCPCS/revenue codes and ensure the record supports the codes billed. If coding/billing guidelines are not followed, the plan may reject or deny the claim, recover/recoup payment, or adjust reimbursement.

Submit both admissions on a single claim for same-day readmissions.
Coding and documentation must support clinical coding criteria used to determine readmission relatedness.
Failure to follow coding/billing guidelines may result in claim rejection, denial, recovery/recoupment, or reimbursement adjustment.

Key Operational Definitions

inv-06: Leave of Absence — definition and operational note.

DefinitionLeave of Absence: an interim period when readmission is expected, and the patient does not require a hospital level of care.

Operational noteWhen a member is placed on a leave of absence and subsequently readmitted within the applicable readmission window, the admissions are treated as part of the same inpatient episode and should be submitted on a single bill (covered days plus leave days) rather than as separate admissions.

Billing implicationOnly one DRG is reimbursed for the combined admission and leave period; providers should include leave days on the original discharge claim per policy instructions.

inv-07: Planned Readmission — definition and examples of scheduled procedures considered planned.

DefinitionPlanned Readmission: acute readmission for a scheduled procedure.

ExamplesScheduled procedures considered planned readmissions include elective surgeries and any acute admission that was arranged in advance as part of care planning.

Treatment under policyPlanned readmissions are excluded from unplanned readmission denial rules and are treated as a single admission for billing when they occur within the policy’s readmission timeframe.

inv-08: Same Hospital System — defines ownership/management relationships considered the same system.

DefinitionSame Hospital System: two or more hospitals owned, leased, sponsored, or contract managed by a central organization.

Operational implicationReadmissions between facilities within the same hospital system are considered within-system transfers for determining whether the readmission is part of the original episode.

Ownership/management relationshipsIncludes hospitals that are owned, leased, sponsored, or contract-managed by the same central organization; these relationships determine system-level status for policy application.

OpenPayer

Reimbursement Policy Inpatient Readmissions

Unplanned Readmission Reimbursement Rules

Required Coding Systems

Provider Requirements and Billing Impacts

Key Operational Definitions