CurrentAnthemPolicy G-13001

Reimbursement Policy Inpatient Readmissions

Defines the health plan's reimbursement rules for unplanned inpatient readmissions to the same hospital within 30 days and identifies exclusions and billing instructions for planned readmissions and leaves of absence. Affects facility inpatient claims paid under DRG methodology for Anthem/AMH Health Medicare Advantage.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification

Effective Date3/25/2025

Next Review Date

Key ActionSubmit same-day readmissions and covered days with leaves of absence on a single UB-04 claim using occurrence span code 74 when applicable.

SourceLink

POLICY UPDATE CHANGES

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

30 daysreadmission period

Same-daysame-day readmissions

One DRGplanned/LOA reimbursement

G-13001policy id

Readmission Coverage Criteria

Unplanned readmission criteria

The health plan will not allow separate reimbursement for certain unplanned inpatient readmissions; clinical review and coding determine applicability.

ALL of the following

Unplanned readmission up to 30 days from discharge
Readmission window

ALL of the following

ONE of
- Readmission for the same or closely related condition or procedure as the prior discharge
- Readmission for an infection or other complication of care

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification

Effective Date3/25/2025

Next Review Date

Key ActionSubmit same-day readmissions and covered days with leaves of absence on a single UB-04 claim using occurrence span code 74 when applicable.

SourceLink

On This Page

ALL of the following

Readmissions occurring on the same day (same date of service) are considered a continuation of initial treatment and part of the original admission; providers should submit both admissions on a single claim
When readmission is planned or member is placed on a leave of absence and ultimately discharged on the same UB-04, providers should submit one bill for covered days and days of leave using occurrence span code 74 to report the dates the leave began and ended; only one DRG will be reimbursed

Coding and Time Window

Required claim coding for leave of absencemixed

Occurrence Span Code 74

Used to report dates the leave began and ended on UB-04 when billing planned leaves of absence

Readmission window

Readmission windowUnplanned readmissions are identified within 30 days from discharge

Same-day readmissionsReadmissions occurring on the same date of service are considered continuation of initial treatment and should be submitted on a single claim

Determination methodClinical coding criteria and/or licensed clinical medical review determine applicability within the 30-day window

Billing, Submission, and Denial Guidance

Billing Rule

Billing for readmissions and leave of absence

Providers must submit one bill when a readmission occurs on the same date of service or when a patient is placed on a leave of absence and is ultimately discharged on the same UB-04 claim. For leave of absence reporting, use occurrence span code 74 and report the dates the leave began and ended. This applies to facilities reimbursed under DRG methodology.

Occurrence span code 74 must be used to report leave start and end dates on the UB-04.
Submit a single UB-04 claim that includes covered days and leave days when discharge occurs on same claim.
Applies to facilities reimbursed under DRG methodology.

Denial Risk

Denial/recoupment risk for unplanned readmissions

The health plan may deny payment or recoup previously paid amounts when a subsequent admission within 30 days is determined to be an unplanned readmission for the same, similar, or related condition. Clinical coding review will determine whether the readmission meets unplanned criteria (same/closely related condition, infection or complication of care, failed surgical intervention, acute decompensation of chronic disease, preventable need, or premature discharge).

Unplanned readmissions within 30 days may be denied or subject to recoupment if for the same or related condition.
Clinical coding and licensed medical review will be used to assess whether the readmission is for an infection, complication, failed surgery, acute decompensation, preventable need, or premature discharge.
Readmissions on the same date of service are considered a continuation of the original admission and should be billed on a single claim to avoid denial.

Key Definitions

Leave of Absence

DefinitionAn interim period when readmission is expected, and the patient does not require a hospital level of care

Billing implicationWhen a leave of absence is planned, providers should include days of leave on the same UB-04 claim (see billing instructions for occurrence span code 74)

Exclusion statusPlanned leaves of absence are excluded from unplanned readmission denials when properly documented and billed

Planned Readmission

DefinitionAcute readmission for a scheduled procedure

Treatment relationshipPlanned readmissions are not considered unplanned and are excluded from separate readmission denial when properly documented

Billing notePlanned readmissions should be billed to reflect the scheduled nature of the admission per provider billing instructions

Same Hospital System

DefinitionTwo or more hospitals owned, leased, sponsored, or contract managed by a central organization

ApplicabilityPolicy applies to readmissions to the same hospital within the same hospital system when they meet the criteria for same or related condition

Transfer considerationTransfers between acute care hospitals within the same system may be treated according to exclusions and billing guidance in the policy