CurrentAnthemPolicy C-17002

Inpatient Readmissions - Facility

Defines Anthem's reimbursement stance for inpatient facility readmissions (within 30 days) and which readmissions will not receive separate reimbursement; applies to facilities reimbursed by DRG or case rate and to members covered by Anthem Blue Cross benefit plans.

Policy Summary

PayerAnthem

PolicyInpatient Readmissions - Facility

Policy CodePolicy C-17002

Change TypeNon-material/administrative

Effective Date05/27/2020

Next Review Date

Key ActionProviders must follow authorization and medical necessity guidelines and proper billing; Anthem may reject or recoup payments if guidelines are not followed and readmissions may be denied separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy review: policy language updated; bullet removed (reason that is medically unnecessary); policy title updated.

Biennial review approved; policy language updated and clinical exclusions removed.

New template policy: removed description section and added definition section.

30 daysreadmission window for nonpayment

DRG or Case Rateapplies to

C-17002policy id

04/28/2021last approval

Inpatient Readmission Coverage Criteria

Coverage criteria for inpatient readmissions

Anthem does not allow separate reimbursement for qualifying readmissions; reimbursement remains for the original admission only.

Subsequent inpatient admission meets the definition of a readmission: admission to the same facility or to another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as the Facility, or (iii) is under common ownership as the Facility, within 30 days from discharge of the original admission; and the subsequent admission is for the same, similar, or related diagnosis or for a complication arising out of the first admission; original admission was reimbursed using DRG or Case Rate methodology.

Timing: readmission occurs within 30 days of discharge from the original admission.

Readmission clinical relationship (one or more of the following must be present)

Subsequent admission is for the same or a closely-related condition or procedure as the prior discharge.

Policy Summary

PayerAnthem

PolicyInpatient Readmissions - Facility

Policy CodePolicy C-17002

Change TypeNon-material/administrative

Effective Date05/27/2020

Next Review Date

SourceLink

On This Page

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Subsequent admission is for an infection or other complication of care from the prior admission.

Subsequent admission is for a condition or procedure indicative of a failed surgical intervention from the prior admission.

Subsequent admission is for an acute decompensation of a coexisting chronic disease present during the prior admission.

Subsequent admission is for a need that could have reasonably been prevented by appropriate care during the prior admission or the post-discharge follow-up period.

Subsequent admission is for an issue caused by a premature discharge from the original admission facility.

Coverage consequence: The Health Plan does not allow separate reimbursement for readmissions that meet these criteria; reimbursement is allowed only for the original admission. Admissions should not be combined to qualify for outlier reimbursement.

Exclusions (these situations are not subject to the readmission nonpayment rule)

Admissions for the medical treatment of cancer, substance abuse, or rehabilitation.
Planned admissions.
Transfers from one facility to another.
Members discharged from a facility against medical advice.
Admissions for covered transplant services during the global case rate period for the transplant.

Applicability: This policy applies to facilities reimbursed for inpatient services by DRG or Case Rate methodology.

Operational note: The Health Plan may utilize clinical coding criteria or licensed clinical medical review to determine if the subsequent admission meets readmission criteria, and reserves the right to reject or deny the claim or to recoup monies previously paid for claims that fall within this policy.

Coding and Time Window

General coding rulesmixed

Standard correct coding applies; use CPT, HCPCS, Revenue codes; billed codes must be supported in medical record.

Readmission window (threshold)

Readmission window30 days from discharge

Applies when subsequent admission is forSame, similar, or related diagnosis or a complication arising from the first admission

Reimbursement impactNo separate reimbursement for qualifying readmissions; reimbursement remains for the original admission only

Provider Billing, Authorization, and Denial Risk

Denial Risk

Follow authorization, coding, and billing rules — risk of denial or recoupment for readmissions

Providers must follow authorization and medical necessity guidelines and proper billing/submission; use industry-standard CPT, HCPCS, and/or Revenue codes that are supported in the medical record. If coding/billing guidelines or reimbursement policies are not followed, Anthem may reject or deny the claim or recover/recoup payment. Readmissions identified under this policy may be denied separate reimbursement; reimbursement is allowed only for the original admission when the subsequent admission meets the readmission criteria (e.g., within 30 days, same or similar diagnosis, complication or failed surgical intervention).

Follow authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
Use industry-standard CPT, HCPCS and/or Revenue codes; billed codes must be fully supported in the medical record.
Anthem may reject/deny claims or recover/recoup payment if guidelines are not followed.
Readmissions meeting policy criteria (e.g., within 30 days for same or related diagnosis or complication) will not receive separate reimbursement; only the original admission is reimbursed.

Key Definitions

Readmission (definition and scope)

Definition of ReadmissionAdmission to the same facility or another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as the Facility, or (iii) is under common ownership as the Facility

Timing requirementWithin 30 days from discharge of the original admission

Clinical relationship requirementSubsequent admission must be for the same, similar, or related diagnosis or for a complication arising out of the first admission

Original admission reimbursement conditionOriginal admission must be reimbursed using DRG or Case Rate methodology for readmission rule to apply

Policy Revision History

04/28/2021revisionLatest

Policy review: policy language updated; bullet removed (reason that is medically unnecessary); policy title updated.

05/27/2020revision

Biennial review approved; policy language updated and clinical exclusions removed.

06/01/2019addition

New template policy: removed description section and added definition section.

08/03/2018revision

Exclusion section updated to allow readmissions criteria to be applied to psychiatric services (exclusion effective 01/01/2019).

07/06/2017approval

Initial Enterprise Facility Reimbursement Committee approval and effective date.