Inpatient Hospital Readmissions (Repeat Admissions) – Medicare Advantage

Policy No: 111
Originally Created: 08/01/2013
Section: Administrative
Last Reviewed: 08/01/2024
Last Revised: 08/01/2024
Approved: 08/08/2024
Effective: 09/01/2024
Policy Applies to: Medicare Advantage

This policy applies to all hospitals.

Readmission is classified as subsequent acute care inpatient admission at the same hospital, and the same patient within 30 days of discharge of the initial inpatient acute care admission.

Leave of Absence Patient is discharged but readmission is expected; according to Centers for Medicare & Medicaid (CMS) Claims Processing Manual, Chapter 3, 40.2.5.

Example - A patient who requires follow-up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence. Hospitals may place a patient on a leave of absence when readmission is expected, and the patient does not require a hospital level of care during the interim period. Examples could include but are not limited to situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately. Institutional providers may not use the leave of absence billing procedure when the second admission is unexpected.

Children’s Hospital - A separately certified children’s hospital either freestanding or hospital-within-hospital that has a CMS certification number that has the last 4 digits in the series 3300-3399; and predominantly treats individuals under 21 years of age.

Readmission to the same hospital (assigned provider identifier by our health plan) within 30 days of discharge of the initial admission is subject to clinical review to determine if the readmission is related to or similar to the initial admission.

• Readmissions occurring on the same day (or within 24 hours) will be processed as a single claim.
• Neither the day of discharge nor the day of admission is counted when determining whether a readmission has occurred.

• Readmissions occurring less than 31 calendar days from the date of discharge will be subject to clinical reviews. If the clinical review indicates that the readmission is for the same or similar condition, it may be considered a continuation of the initial admission for the purposes of reimbursement.

The two Diagnosis Related Group (DRG) hospital claims will be consolidated into one, combining all necessary codes, billed charges, and length of stay. The maximum allowable for the consolidated claim will be recalculated using the DRG methodology defined in the hospital contract.

This policy applies to the following but not limited to:

• Clinically related readmissions
• Planned readmissions or leave of absence

• Emergent readmissions

This policy does not apply to the following:

• Transfer from one inpatient stay at an acute care hospital to an inpatient stay at another acute care hospital
• Patient discharged from the hospital against medical advice
• Planned readmissions for cancer chemotherapy, transfusion for chronic anemia or other similar repetitive treatments
• Readmission for unrelated condition
• Readmission for the medical treatment of rehabilitation care
• Readmission for pre-delivery obstetrical care
• Psychiatric and substance abuse
• Transplants
• Children's Hospitals

• Critical Access Hospitals

Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing

Centers for Medicare & Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) Manual. Readmission Review, Chapter 4, Section 4240

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