CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO27

Inpatient Readmissions

Defines the plan's process for reviewing and adjudicating hospital inpatient readmissions (typically within 30 days) and the circumstances under which additional reimbursement may be denied or reduced; applies to hospitals and facilities billing Blue Cross Blue Shield New Mexico members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyInpatient Readmissions

Policy CodePolicy CPCPO27

Change TypeNo material changes

Effective DateJan 24, 2022

Next Review Date

Key ActionPre-authorize all days for the initial admission and any readmission; submit medical records with the claim or expect a medical record request for claim review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmission review timeframe

MCG 25th Editiondischarge planning resource

appliessame TIN/contract

listedexclusions

Inpatient Readmission Review and Adjudication

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Inpatient readmission review and adjudication criteria

The Plan may deny or reduce additional reimbursement for inpatient readmissions that are considered continuations of the initial admission or otherwise meet review criteria.

Readmission timeframe: Readmissions occurring within 30 days (or the number of days specified in the provider contract) of the initial discharge for the same, similar, or related diagnosis are subject to review and possible denial or reduced payment.

Review triggers

Readmissions related to the first admission.
Preventable readmissions (e.g., infection from the initial admission, failed surgical or interventional procedure).
Premature hospital discharge from the same facility or a facility within the same health system or under the same provider contract.
Unplanned surgery resulting in a continuation of the initial admission.
Medical necessity concerns identified on review.
Exacerbation of symptoms of a chronic illness leading to readmission.

Adjudication rules

Initial admission and subsequent readmission(s) will be considered a single admission for adjudication.
All authorized days for the initial admission and readmission will be combined to determine the approved length of stay; all days in-between admissions will not be reimbursed.
All days for the initial admission and readmission must be pre-authorized; medical records may be requested if not submitted with the claim and reviews may be pre-adjudication or post-payment.
All services for the initial admission and readmission will be considered as a single claim; multiple readmissions will not be separately reimbursed when stays are reimbursed per case/per admission; if the initial admission has been reimbursed, claims will be combined to determine reimbursement.
If combined authorized days for the initial admission and readmission exceed the average length of stay for the assigned DRG, high-trim days will not be reimbursed in addition to the assigned DRG reimbursement.

Scope and applicability

Policy applies to all hospitals and facilities, including those within the same health system practicing under the same tax identification number (TIN) or subject to the same provider contract.
MCG Discharge Planning Tool is used as the resource for discharge planning and follow-up; the Plan may coordinate services with hospital discharge planning staff and the admitting physician.

Pre-authorization and Documentation Requirements

Prior Authorization

Prior Authorization and Documentation Required for Combined Admissions

All days for combined admissions (initial admission and any readmissions) must be pre-authorized and documented. Medical records may be requested and claim adjudication depends on medical record review. Failure to obtain prior authorization or provide requested documentation may result in denial or non-reimbursement of high-trim days or entire readmission days.

Pre-authorize all days for the initial admission and any readmissions (combined authorization required).
Provide complete medical records with the claim; if records are not submitted, expect a request and possible post-payment review.
Documentation must support that readmission is clinically related to the initial admission when applicable; lack of documentation may lead to denial.
If combined authorized days exceed the DRG average length of stay, high-trim days will not be reimbursed.
Multiple readmissions will not be separately reimbursed when stays are adjudicated as a single case/admission.

Key Definitions

Hospital readmission

DefinitionReturn hospitalization to an acute care hospital that follows a prior acute care admission within thirty (30) days of discharge for a clinically related admission.

Review timeframeReadmissions occurring within 30 days of the initial discharge are subject to review.

ScopeApplies to readmissions to the same or another acute care hospital under the same agreement when the readmission is clinically related.

Potentially Preventable Readmission (PPR)

DefinitionA readmission considered preventable when associated with factors such as infection or complication from care provided during the initial admission, an unsuccessful surgical intervention requiring a subsequent procedure, premature discharge, or exacerbation of a chronic illness identified during review.

PurposeIdentifying Potentially Preventable Readmissions (PPR) supports medically appropriate discharge planning and follow-up to improve quality of care and outcomes.

ExclusionsReadmissions for occurrences unrelated to the initial discharge are not classified as PPR and are excluded from PPR review.