CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP027

Inpatient Readmissions

Defines Blue Cross Blue Shield - Oklahoma's process for reviewing and adjudicating reimbursement for inpatient stays that result in subsequent readmissions for the same, similar, or related diagnosis; applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyInpatient Readmissions

Policy CodePolicy CPCP027

Change TypeAnnual review — no material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionSubmit supporting documentation promptly upon request to support billed services for readmission claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single-admission adjudicationAdjudication approach

denial or reduction possiblePayment outcome

exclusions listedExclusions

case-by-case reviewReview process

Readmission Review and Adjudication Criteria

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Readmission is for the same, similar, or related diagnosis to the initial admission and to the same hospital.

Plan reviews claims for readmissions occurring after initial discharge for the same, similar, or related diagnosis to the same hospital (per contract).

Continuing-treatment reasons (one or more)

Preventable readmissions — e.g., those potentially avoidable through discharge education, care coordination, or related to complications of initial care (such as heart failure exacerbation, infection, failed procedure).
Includes readmissions preventable by discharge education, care coordination, or related to complications of initial care.
Premature hospital discharge leading to continuation of initial treatment.
Unplanned surgery that results in continuation of the initial admission.
Condition or procedure attributed to readmission due to a failed surgical procedure or interventional service.
Infection attributable to the initial admission.
Exacerbation of symptoms of a chronic illness that continues the initial course of treatment.

Readmissions excluded from review — certain admission types are not subject to this readmission adjudication (examples noted in policy).

Exclusions include psychiatric/substance abuse, transplant services, discharges against medical advice, multiple trauma, burns, and staged procedures per commonly accepted practices.

ALL of the following

Initial admission and readmission may be adjudicated as a single admission; all services for both stays will be considered as a single claim.
If combined authorized days cause the stay to exceed the average DRG length of stay, high-trim days will not be reimbursed in addition to the assigned DRG reimbursement, to the extent allowed under contract terms.
If combining claims results in an additional outlier payment, any such outlier payment (to the extent allowed under contract terms) will only be reimbursed on the initial admission.
Multiple readmissions will not be separately reimbursed when each stay is reimbursed per case/per admission.
If the initial admission has already been reimbursed, claims will be combined to determine final reimbursement adjustments.

Claim review timing and documentation

A claim review may occur pre-adjudication or post-payment; the Plan may request supporting documentation and providers should submit additional documentation upon request.

Coding and Length-of-Stay Considerations

General coding requirementsmixed

Claims should be submitted using HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC) and follow industry-standard coding guidelines.

Average length of stay (DRG) — combined stay exceeding average DRG LOS

Policy actionIf authorized days from the readmission cause the combined admission to exceed the average length of stay for the assigned DRG, high-trim days will not be reimbursed in addition to the assigned DRG reimbursement, to the extent allowed under contract terms.

Combined-admission treatmentThe initial admission and readmission will be considered as a single admission for adjudication and payment determination.

Outlier payment ruleIf combining admissions results in additional outlier payment, any outlier amount will only be reimbursed on the initial admission, to the extent allowed under contract terms.

Claim combinationAll services for the initial admission and readmission will be treated as a single claim for both inpatient stays.

Previously paid initial admissionIf the initial admission has already been reimbursed, claims will be combined to determine final reimbursement.

Documentation, Claim Review, and Payment Adjustment Actions

Documentation Required

Documentation Request and Claim Review Timing

BCBSOK may request supporting documentation to validate services billed and to confirm that coding and billing accurately reflect care rendered. Providers must submit requested medical records or other documentation when asked. Failure to provide adequate documentation may affect claim processing and reimbursement.

Documentation may be requested for initial admissions and readmissions.
Claims are reviewed on a case-by-case basis and may be reviewed pre-adjudication or post-payment.
Claim review elements may include provider contract assessment, diagnosis related to the initial admission, PPR, prior admissions and discharge dates of service, and coding/documentation review.
Submission of any code should be fully supported in the medical documentation.

Billing Rule

Adjudication and Payment Adjustment Actions

Claims for an initial admission and subsequent readmissions may be combined and adjudicated as a single admission. Payment adjustments may be made based on the combined review and in accordance with contract terms.

The initial admission and readmission will be considered a single admission for adjudication.
If authorized days from the readmission cause the combined admission to exceed the average length of stay for the assigned DRG, high-trim days will not be reimbursed in addition to the assigned DRG reimbursement, to the extent allowed under contract terms.
If combining claims results in additional outlier payment, any outlier amount (if applicable and allowed under contract terms) will only be reimbursed on the initial admission.
All services for the initial admission and readmission will be considered as a single claim for both inpatient stays; multiple readmissions will not be separately reimbursed when each stay is reimbursed per case/per admission.
If the initial admission has already been reimbursed, claims will be combined to determine any reimbursement adjustment.

Key Definitions

Readmission — definition

DefinitionA readmission is a return hospitalization to an acute care hospital that follows a prior, clinically related, acute care admission.

Review goalThe Plan's Inpatient Readmissions review process aims to support quality of care and outcomes to avoid Potentially Preventable Readmissions (PPR).

Exclusion — unrelated eventsReadmissions for occurrences unrelated to the initial discharge are not classified as PPR and are excluded from the review process.

Potentially Preventable Readmission (PPR) — definition and examples

DefinitionA Potentially Preventable Readmission (PPR) is a readmission that may be avoidable through improved discharge education, care coordination, or other interventions.

Common examplesHeart failure exacerbation; infection or complication related to the initial admission; need for the same procedure or treatment as the initial admission; procedure for failed surgical intervention from the initial admission.

Provider encouragementProviders are encouraged to improve communication and care coordination and engage members and caregivers in the discharge process to reduce avoidable readmissions.