CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP027

Inpatient Readmissions Reimbursement Review

Governs Blue Cross Blue Shield Illinois' process for reviewing and adjusting reimbursement for inpatient hospital readmissions occurring within 30 days (or a contract-specified interval) of discharge when the readmission is for the same, similar, or related diagnosis or condition; affects participating providers and claims processing.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyInpatient Readmissions Reimbursement Review

Policy CodePolicy CPCP027

Change TypeNo material changes

Effective DateDec 4, 2024

Next Review Date

Key ActionIf a readmission claim is denied, submit a corrected claim combining the initial and readmission admissions using the appropriate leave of absence revenue code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmission review window

may deny/reducereimbursement outcome

CPCP027policy identifier

listedexclusions

corrected claimpost-denial action

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Readmission Review and Reimbursement Criteria

Readmission review and reimbursement criteria

Covered when the following conditions are met — the Plan may deny or reduce reimbursement when readmission is determined to be a continuation of the initial admission or otherwise preventable; certain admissions are excluded from review.

Readmission occurs within thirty (30) days, or the number of days specified in the provider contract, from the date of discharge from the same acute care hospital following treatment for the same, similar, or related diagnosis or condition.

AND one or more of the following

Readmission is related to the first admission (continuation of initial treatment).
Readmission is potentially preventable (examples include heart failure exacerbations, infections related to the initial admission, or failed surgical/interventional procedures).
Readmission follows a premature hospital discharge leading to return admission.
Unplanned surgery results in continuation of the initial admission.
Condition or procedure attributed to readmission due to a failed surgical procedure or interventional service.
Exacerbation of symptoms of a chronic illness resulting in return admission.

When the Plan determines the readmission meets the above criteria, payment may be partially or wholly denied or reduced.

Exclusions — do NOT apply to readmission review

Psychiatric or substance abuse admissions.
Transplant services admissions.
Readmission due to discharge against medical advice.
Multiple trauma admissions.
Burns admissions.
Neonatal and obstetrical admissions.
Staged procedures performed according to commonly accepted practices.

Operational note: The Plan may request supporting documentation to determine eligible reimbursement; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Operational note: A claim review may occur pre-adjudication or post-payment. If a readmission claim is denied, providers should submit a corrected claim combining the initial and readmission admissions with appropriate leave of absence revenue coding as required by billing rules and the provider contract.

Billing Instructions and Readmission Interval

Corrected claim billing instructionmixed

Combine initial and readmission inpatient claims as a single admission; use appropriate leave of absence revenue code for any non-inpatient days.

Readmission interval

Standard interval30 days from date of discharge

Contract variationsInterval may be different if specified in the provider contract (contract governs when conflict exists)

ApplicationApplies to inpatient readmissions to the same acute care hospital for same, similar, or related diagnosis/condition

Documentation, Claim Review Timing, and Denial Risk

Documentation Required

Documentation and Claim Review Timing

The Plan may request supporting documentation to determine eligible reimbursement. Claims may be reviewed either pre-adjudication or post-payment; reviews can include contract assessment, diagnosis related to the initial admission, potentially preventable readmission (PPR) determination, prior admissions and discharge dates of service, and coding/documentation review. If documentation does not support submitted codes or services, processing and reimbursement may be impacted.

Reviews may be conducted before payment or after payment and may require submission of medical records or other supporting documentation.
Failure to adhere to coding and billing policies may affect claims processing and reimbursement.

Denial Risk

Denial Risk for Related Readmissions

A readmission for an inpatient stay within thirty (30) days (or the contractually specified timeframe) from discharge for the same, similar, or related diagnosis or condition may be considered a continuation of the initial admission. In such cases, payment for the readmission may be partially or wholly denied.

Key Definitions

Definition of Readmission

DefinitionReturn to an acute care hospital within thirty (30) days, or the number of days specified in the provider contract, from the date of discharge from the same acute care hospital following treatment for the same, similar, or related diagnosis or condition.

ScopeCovers readmissions considered continuation of the initial admission or related to initial treatment

ExclusionsReadmissions for unrelated occurrences after the initial discharge are not classified as readmissions for this review and are excluded

Potentially Preventable Readmission (PPR)

DefinitionPotentially preventable readmissions (PPR) are readmissions that may be avoided with improved communication, discharge education, or care processes.

Examples - cardiac