| 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) |
| 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) |
