CurrentPremera BluecrossPolicy N/A

Guidelines for Bundling Admissions

Rules Premera Blue Cross Medicare Advantage uses to determine when two hospital admissions will be combined (bundled) for DRG reimbursement and billing, and circumstances when admissions should be billed separately. Applies to hospitals/facilities treating Premera Medicare Advantage members.

Policy Summary

PayerPremera Bluecross

PolicyGuidelines for Bundling Admissions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReview and document discharge rationale (AMA form, discharge plan, clinical notes) to support whether readmissions should be billed separately or combined.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmissions reviewed for possible bundling

multipleexplicit discharge/readmission scenarios described

severalsettings assessed for bundling

possibleaudit adjustments possible

Bundling and Separate Billing Criteria

Bundling decision criteria

Scenarios determining when two hospital admissions will be combined (bundled) for DRG reimbursement versus billed separately. Covered/combined when ALL of the following scenario-specific rules apply as described below:

ALL of the following

AMA discharge: If member leaves against medical advice (AMA) and the hospital record documents AMA (e.g., signed AMA form, physician or nurse progress note, physician order), the admissions are billed separately.
Planned readmission: If member is discharged with a documented plan for readmission for additional services within an appropriate timeframe (based on benefits or provider request) and the subsequent care was anticipated, combine the admissions as a planned readmission. If billed separately, Premera may make an audit adjustment to combine the admissions; provider appeal rights apply.
Unrelated condition or appropriate discharge plan:

Policy Summary

PayerPremera Bluecross

PolicyGuidelines for Bundling Admissions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReview and document discharge rationale (AMA form, discharge plan, clinical notes) to support whether readmissions should be billed separately or combined.

SourceLink

On This Page

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DRG Bundling and Timing

DRG bundling guidancemixed

No specific CPT/ICD/DRG codes listed; document describes DRG reimbursement combination rules.

Readmission time window

Readmission time window30 days — readmissions within 30 days of discharge are reviewed for possible bundling into a single DRG reimbursement episode

Scope of reviewApplies to facilities reimbursed by DRGs (hospitals/facilities) when the member has the same or a similar diagnosis or related event

Potential actionPremera may combine two admissions into one payment episode for DRG reimbursement when criteria are met

Audit consequenceIf a facility bills admissions separately, Premera may make audit adjustments to combine admissions

Documentation and Billing Actions for Readmissions

Documentation Required

Readmission review and audit

Readmissions that occur within 30 days of discharge are reviewed for facilities reimbursed by DRGs when the member has the same or a similar diagnosis or related event. Premera may combine two admissions into one for DRG reimbursement when criteria below are met. These guidelines are subject to change and additional information is in the Care Management chapter of the Premera provider manual.

Criteria assessed for discharges to home, SNF, IRF, psychiatric facility, basic nursing home, or LTAC
If facility acknowledges discharge screens not met, admissions may be combined without clinical review
If facility does not acknowledge, Premera will perform clinical review to assess bundling criteria

Billing Rule

Planned readmission handling

If the member was discharged with a documented plan for readmission for additional services within an appropriate time frame (for example for scheduling or physician availability), the two admissions are treated as a planned readmission and are combined for billing purposes. If the subsequent admission is for an anticipated care episode (including recognized postoperative monitoring or an expected sequela), combine the admissions.

Billing: Combine admissions as a planned readmission when a documented plan for return exists
Financial recovery: If hospital bills separately, an audit adjustment may be made to combine admissions
Provider appeal rights: Can be appealed when combined as planned readmission

Documentation Required

AMA discharges

Discharges against medical advice (AMA) are considered regular discharges. If a member leaves AMA and later requires readmission, bill the admissions separately when the hospital record documents that the member initiated the interruption (e.g., AMA form signed, physician/nurse notes).

Documentation: Hospital record should include notation the member left AMA (physician order, AMA form, progress note)
Billing: Bill admissions separately if hospital record shows member initiated the interruption
Appeals: Provider decisions related to AMA bundling cannot be appealed

Key Term Definitions

AMA discharge

DefinitionDischarge against medical advice (AMA): member leaves the hospital against medical advice with documentation such as a signed AMA form or physician/nurse progress note

Billing treatmentAdmissions are billed separately when the hospital record documents AMA

Required documentationExamples of acceptable documentation include physician orders noting 'discharged AMA', a signed AMA form, or progress notes indicating the member left AMA

Planned readmission

DefinitionPlanned readmission: a readmission that was documented and scheduled within an appropriate timeframe for additional services based on member benefits or provider request

Billing treatmentCombine the admissions as a planned readmission for DRG reimbursement when a documented plan for readmission exists

Audit consequenceIf a hospital bills planned readmissions separately, Premera may make an audit adjustment to combine the admissions

ExamplesDischarge for provider or scheduling convenience with an anticipated return for services; anticipated postoperative care readmissions may be combined

Premature discharge

DefinitionPremature discharge: discharge when clinical discharge screens were not met (for example: unstable vital signs, abnormal lab results)

Billing treatmentSubsequent readmissions after a premature discharge are combined as a continuation of care for billing/DRG purposes

Facility acknowledgementIf the facility acknowledges the member did not meet discharge screens, admissions can be combined without additional clinical review; otherwise Premera will perform clinical review

Audit consequenceIf a hospital bills the admissions separately, Premera may make an audit adjustment to combine the admissions; provider appeal rights may apply