Inpatient Readmission Payment Policy
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Governs reimbursement for inpatient readmissions to acute care hospitals within fifteen (15) days of a prior discharge for Blue KC Commercial and specified lines of business; affects professional, facility, and lab providers.
Readmittance time frame changed from 30 days to 15 days.
Removed 'same or similar hospital' language and clarified definition of 'same system'.
Inpatient Readmission Coverage and Payment Treatment
Inpatient readmission coverage criteria
Covered when ALL of the following are met:
ALL of the following
ALL of the following
ALL of the following
- Readmission must occur within fifteen (15) calendar days of a prior inpatient discharge.
ALL of the following
- Readmission must be unplanned and for a condition related to the most recent inpatient stay.
Examples (not exhaustive)
- The same or a closely related condition or procedure as the original admission.
- An infection or other complication of care arising from the original admission or post-discharge care.
- A condition or procedure indicative of a failed surgical intervention.
- An acute decompensation of a coexisting chronic disease that may be related to care during the initial admission or follow up care after discharge.
- Clinical instability of the patient's condition prior to discharge (e.g., premature discharge).
ALL of the following
- Readmission applies when admission is to the same or another acute care hospital in the same system as defined by policy (hospitals that directly control, are controlled by, or are under common control, including wholly owned or operated hospitals).
ALL of the following
ALL of the following
- Hospitals must submit relevant medical records and supporting documentation (for example, prior discharge summary, current admission history & physical, orders, ER records, progress notes) with the inpatient authorization request to determine relatedness to the prior stay.
ALL of the following
ALL of the following
- Providers are responsible for reporting appropriate codes and accurate documentation; Blue KC reserves the right to validate coding accuracy and investigate whether the readmission was related to the previous inpatient stay.
Billing, Claim Combination Rules, and Code Lists
| No codes listed |
Documentation and Submission Requirements
Submit prior discharge and current admission records with authorization
The hospital must include all relevant medical records and supporting documentation with the inpatient authorization request so Blue KC can determine whether the readmission is related to the most recent inpatient stay.
- Discharge Summary from the previous discharge
- Admission History & Physical from the readmission
- Physician orders
- Emergency records
- Progress notes
Key Term Definitions
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