Hospital inpatient readmissions

Unless otherwise stated in the facility contract, our policy is to deny readmissions within 30 days of discharge and consider them a part of the original admission. 

  • Medicaid and the Healthy Michigan Plan define readmissions as within 15 days of discharge.
  • Same-day readmissions are considered a continuation of care and one claim should be submitted.

Payment guidelines for readmissions

Use the list below to see when a second DRG or episode of care is payable.

Guidelines 1-5 supersede 6-8 when more than one apply.

One allowable payment

1. Patient 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

Billing: Separate

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Examples:

  • 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

 

2. Patient 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

Billing: Separate

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Examples:

  • 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

3. Patient-requested discharge because of uncertainty about whether or not to undergo further treatment or for other personal reasons, is readmitted for definitive care

Billing: Separate

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: Newly diagnosed pelvic mass requiring surgery. Patient requests surgery after the holidays

4. Patient discharged from the hospital after surgery, but readmitted within 30 days with a direct or related complication from the surgery

Billing: Separate

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher.

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: An open appendectomy is performed. The patient returns in 3-5 days with a wound infection requiring hospitalization

5. Patient discharged from the hospital with a documented plan to readmit within 30 days for additional services

Billing: Separate

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: Administrative reasons, e.g. surgeon was not available

Two allowable DRG payments or episodes of care

6. Patient requires readmission due to an unrelated condition.

Billing: Separate

Financial recovery: None

Appeal rights N/A - Second admit is payable

Applies to all plans (15-day readmissions for Medicaid)

Examples:

  • Pregnancy/delivery first admission
  • Readmission with a fractured ankle

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

For exceptions, see 1. above

Billing: Separate

Financial recovery: None

Appeal rights N/A - Second admit is payable

Applies to all plans (15-day readmissions for Medicaid)

Examples: COPD or CHF exacerbation (unless otherwise noted in 1, above)

8. Newborn infants readmitted within 30 days

Billing: Separate

Financial recovery: None

Appeal rights N/A - Second admit is payable

Applies to all plans (15-day readmissions for Medicaid)

Example: Newborn readmitted with hyperbilirubinemia


Requesting readmission reimbursement

A readmission denial may be appealed by the facility based on readmission guidelines and/or contract. Submit a Level 1 Appeal Form with medical documentation.

  • All readmissions are reviewed against Priority Health readmission guidelines.
  • Determinations for approval or denial are made based on readmission guidelines and/or a Medical Director decision.