Reminder: Updated billing guidelines for hospital readmissions

Situation

Billing

Financial recovery

Appeal rights

Comments

Patient leaves against medical advice and requires a subsequent readmission.

Separate

None

N/A

Documentation should show that the patient signed out against medical advice. Physician writes "discharged AMA" in physician orders, the patient signs AMA form when leaving or written notification (from a physician or nurse) in progress notes indicates that patient left against medical advice. Any other discharge is considered a regular discharge.

Patient requests discharge because of uncertainty about further treatment or for other personal reasons.

Bill admissions separately if the medical record documentation shows the patient initiated the interruption.

None

N/A

A readmission will be considered separate if the patient needs to return home or requests time to make a major health care decision.

Patient is discharged to allow resolution of a medical problem that, unless resolved, is a contraindication to the medically necessary care that will be provided during the second admission.

Separate

None

N/A

Example: Discharge awaiting normalization of clotting times prior to a surgical intervention, the medical necessity for the interruption of care must be clearly documented.

Patient meets responder criteria and has an appropriate discharge plan, but requires readmission due to an unrelated condition or a new occurrence of some condition.

Separate

None

NA

Documentation must include a discharge plan that is appropriate and reasonable. Discharge plans should include the patient's ability to follow the treatment plan after discharge. Example: Admission No. 1 is for an open cholecystectomy. Procedure and postoperative course are uneventful. Discharged in stable condition. Admission No. 2 is through the ER for multiple injuries due to a motor vehicle accident.

Situation

Billing

Financial recovery

Appeal rights

Comments

Patient is discharged before all medical treatment is rendered, and care during the  second admission should have occurred during the first admission.

Combine admissions as an unplanned readmission unless plans are appropriately made for outpatient follow-up of medical conditions identified at admission. (Previously referred to as “continuation of care”)

If a hospital bills both as separate admissions, an audit adjustment will be made to combine the admissions.

Yes

Example: Patient had a hysterectomy. The day prior to discharge, fever of 101.2, WBC 14.0, incision has edema, erythema and a small amount of drainage. The day of discharge temperature 99.4, incision has increased erythema, edema and drainage. Patient discharged home, no antibiotics prescribed. Patient meets responder criteria for a short stay surgery. Readmitted two days later with fever and cellulitis of the incision requiring IV antibiotics. Documentation in the medical record does not support the fever or the increasing edema, erythema and incisional drainage were addressed during the first admission. Combine the admissions as an unplanned readmission.

Patient is discharged without the responder and clinical criteria being met.

Combine admissions as an unplanned readmission. (Previously referred to as “premature discharge”).

If the hospital bills both as separate admissions, an audit adjustment will be made to combine the admissions.

Yes

BCBSM clinical review supports that the patient was prematurely discharged resulting in an unplanned readmission.

Patient is discharged from the hospital with a documented plan to readmit within 14 days for additional services.

Combine admissions as a planned readmission.

If a hospital bills both as separate admissions, an audit adjustment will be made to combine the admissions.

Yes

The care rendered during the subsequent admission was anticipated. Example: A discharge for hospital or physician convenience; the surgeon is away or the operating room is booked until the following week.