CurrentBlue Cross Blue Shield - MainePolicy G-13001

Inpatient Readmissions Reimbursement

Governs reimbursement for inpatient readmissions to facilities reimbursed under a DRG methodology for AMH Health (Blue Cross Blue Shield - Maine). Applies to participating providers and facilities submitting inpatient claims.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyInpatient Readmissions Reimbursement

Policy CodePolicy G-13001

Change TypeAdded planned readmission/LOA language

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionSubmit one bill for the covered admission and any leave of absence when the patient is ultimately discharged and provide supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Planned readmission/leave of absence language was added to the policy.

Definition section and related_policy section were updated.

30 daysreadmission timeframe considered related to index admission

24 hourssame-hospital continuation window

DRGpayment methodology affected

Exclusions listconditions/services excluded from readmission adjustment

Participating providers

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Readmission Coverage Determination

Readmission determination criteria

AMH Health will not allow separate reimbursement for certain inpatient readmissions and applies clinical review to determine relatedness and exceptions. Readmissions within the specified timeframe, related clinical conditions, planned readmissions, and listed exclusions govern payment determination.

ALL of the following

Readmissions up to 30 days from discharge are considered for relatedness determination.<= 30 days
Readmissions occurring within 30 days for symptoms related to, or for evaluation and management of, the index admission are considered part of the original admission.

Related clinical reasons (any of)

Infection or other complication of prior care.
Same or closely related condition or procedure as the prior discharge (including situations indicative of failed surgical intervention).
A need that could have reasonably been prevented by provision of appropriate care during prior discharge or post-discharge follow-up.
Acute decompensation of a coexisting chronic disease.
Issue caused by a premature discharge from the same facility.

Same-hospital continuation

Readmission to the same hospital on the same date of service is considered a continuation of initial treatment.
Services rendered within 24 hours from time of discharge to time of readmission are defined as continuation of the initial admission.

Planned readmission / Leave of absence

Planned readmissions and leaves of absence are treated as a single admission; only one DRG will be reimbursed and providers must submit one bill when the patient is ultimately discharged.
Submit one bill for the covered admission and any leave of absence when the patient is ultimately discharged.

Exclusions (any of)

Admissions for treatment of cancer.
Neonatal/newborn admissions.
Obstetrical deliveries.
Behavioral health admissions.
Rehabilitation care.
Sickle cell anemia.
Transplants.

ALL of the following

AMH Health reserves the right to recoup or recover monies previously paid on a claim that falls within the readmission guidelines.
This policy applies to facilities reimbursed for inpatient services by a DRG methodology.

Coding and Timeframes

Coding standardsmixed

Standard correct coding applies

Use industry standard CPT, HCPCS, and revenue codes supported by medical record documentation.

Readmission window

Readmission window30 days

Relatedness timeframeReadmissions up to 30 days from discharge are considered for relatedness determination

Clinical review appliedClinical criteria and/or licensed clinical medical review used to determine if admission is related

Billing, Claims, and Provider Responsibilities

Billing Rule

Bill single admission for planned readmission/leave of absence

Submit one bill for the covered admission and any leave of absence when the patient is ultimately discharged; provide documentation that supports billed services and diagnoses.

Treat planned readmissions and leaves of absence as one admission with a single DRG and one final bill submitted at ultimate discharge.
Include medical record documentation that supports the billed services and diagnoses for the combined admission and any interim leave.

Denial Risk

Claims subject to review and payment adjustment

Claims may be rejected, denied, or adjusted if coding, billing guidelines, or medical necessity are not met.

Key Definitions

Leave of Absence

DefinitionInterim period when readmission is expected and the patient does not require a hospital level of care.

Billing treatmentTreated as part of the same admission for planned readmission/LOA; one DRG and one bill submitted at final discharge

DocumentationProviders should document that the period was an authorized or expected leave and support billed services and diagnoses

Planned Readmission

DefinitionNon-acute readmission for a scheduled procedure.

Treatment under policyPlanned readmissions are treated as one admission with the index stay; only one DRG reimbursed