Readmissions within 30 days

Use this chart to help find out when a second DRG or episode of care is payable.  NOTE: If a readmission qualifies for payment under guidelines 1-5 AND 6-8 below, guidelines 1-5 will supersede 6-8.

Same-day readmissions: Considered a continuation of care. One claim should be submitted.

Jump down to:

One allowable payment
Pays the higher of the two claims/the higher episode of care
Guideline Billing Financial recovery Appeal rights Examples Product
1. Patient is discharged: a) before all medical treatment is rendered or b) without an adequate discharge plan or c) where care during the second admission could have occurred during the first admission Separate If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher Yes

Medication reconciliation is not complete/accurate

The medication route/frequency and purpose are not clearly communicated for all discharge medications

The follow-up appointment with the patient's provider is not scheduled in an appropriate time frame (based on patient risk) and/or is not documented on the discharge instructions

The signs and symptoms to watch for post-discharge are not documented and/or there is no clear action plan in the event of their occurrence

Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
2. 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 a planned second admission Separate If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher Yes

Discharged to await normalization of clotting times prior to a surgical intervention. The medical necessity for interruption of care must be clearly documented.

Patient has ankle fracture. Internal fixation scheduled for 7-10 days

Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
3. Patient requests discharge because of uncertainty about whether or not to undergo further treatment or for other personal reasons, and is readmitted for definitive care Separate If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher Yes
Newly diagnosed pelvic mass requiring surgery.  Patient requests surgery after the holidays Fully funded,
Self-funded,
Medicare,
Medicaid (15-day readmissions)
4. Patient is discharged from the hospital after surgery, but is readmitted within 30 days with a direct or related complication from the surgery Separate If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher. Yes An open appendectomy is performed. The patient returns in 3-5 days with a wound infection requiring hospitalization Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
5. Patient is discharged from the hospital with a documented plan to readmit within 30 days for additional services Separate If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher Yes Administrative reasons, e.g. surgeon was not available Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
Two allowable DRG payments or episodes of care
Guideline Billing Financial recovery Appeal rights Examples Products
6. Patient requires readmission due to an unrelated condition. Separate None NA - Second admit is payable

Pregnancy/delivery first admission

Readmission with a fractured ankle

Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)

7. Patient requires readmission due to a reoccurrence of the same condition

For exceptions, see 1. above

Separate None NA - Second admit is payable COPD or CHF exacerbation (unless otherwise noted in 1. above) Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
8. Newborn infants readmitted within 30 days Separate None NA - Second admit is payable Newborn readmitted with hyperbilirubinemia Fully funded, Self-funded, Medicare, Medicaid (15-day readmissions)
Last modified: 4/18/2014
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