Reducing Readmissions Is a Team Effort

OIG is targeting high rates for these services, so work together to be sure yours are necessary.

By Barbara Aubry, RN, CPC, CHCQM, FAIHQ
As a regulatory analyst for 3M Health Information System, I spend a portion of each day reviewing regulatory changes and updates, Office of Inspector General (OIG) actions, the Centers for Medicare & Medicaid Services (CMS) releases, and a myriad of healthcare industry news feeds. My goal is to track what the industry is up to from a regulatory perspective and determine how those changes are likely to affect physicians and hospitals.

The Story Behind Same-day Readmissions

The OIG “mines” claims data to identify patterns and trends. They look for specific criteria—usually anything that gives the appearance of overutilization, overcharging, upcoding, or poor quality of care.
Years ago, facilities could charge a diagnosis-related group (DRG) for each admission. Based on trends in claims data, the OIG wondered if hospitals might be encouraging readmissions to increase revenue. Based on this, in 2004 CMS implemented an edit to reject subsequent claims for beneficiaries who were readmitted to the same hospital on the same day. Per the Medicare Claims Processing Manual (Pub. 100-04, ch. 3, § 40.2.5), “If a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay’s medical condition, the hospital is entitled to only one DRG payment and should combine the original and subsequent stays into a single claim.”

OIG Takes Aim at Same-day Admissions

Same-day hospital readmissions are part of the OIG’s 2013 Work Plan, and they are serious: The New York Times reported that in the fall of 2012, CMS levied financial penalties against 2,127 hospitals believed to have high readmission rates (“Hospitals Face Pressure to Avert Readmissions”). Of that total, 307 will be penalized 1 percent of revenue for every regular Medicare admission for the next five years. The penalties result in multimillion dollar losses for some facilities.
It comes as no surprise that the federal government will continue its focus to reduce healthcare costs. Medicare spent $556 billion in 2012 with a projected growth rate of 4 percent per year. It’s expected the government will recoup $300 million in readmission penalties this year alone.
Readmission rates are too high—I don’t think anyone will argue against that. But there are legitimate cases during which readmission can occur.

Clinical Reasons for Readmissions

As a nurse and former case manager, I am familiar with many legitimate (and unfortunate) reasons for readmissions. These include:

  • Poorly managed chronic illnesses
  • Multiple diagnoses causing complications
  • Medication, treatment, follow-up noncompliance
  • Lack of understanding of the discharge plan
  • Poor discharge teaching
  • Language barriers
  • Inability of the discharge planner to get needed services in the home on the day of discharge
  • Limited or nonexistent family or community support
  • Concomitant mental illness, substance abuse, or other disability
  • Age, frailty, homelessness
  • End-of-life needs not met because patient is not in hospice

I could go on, but you get the drift. People have many complicated physical, emotional, and psycho-social needs that must be met. When those needs are not met, they return to the hospital, where they are able to get the care required.
In addition to clinical reasons for readmissions, there are other reasons, as well. Sometimes, a bed is urgently needed by a sicker patient and early discharges must be made; or patients may use up their allotted days of healthcare coverage based on utilization review and are prematurely discharged.

Look for Trends

By now you may be wondering how coders can impact readmission rates. It’s actually quite simple: You, the coder, know best the diagnoses most often seen. Not only do you recognize the diagnoses, but you begin to learn the names of the frequent flyer patients because they are often in house. You are a valuable resource and your knowledge should be shared to help reduce readmissions.
You will see patterns: For instance, Dr. X’s chronic heart failure patients bounce back on a regular basis. The usual scenario is: emergency department (ED) visit, observation, short stay admission, discharge, followed by ED admission for the same complaint and diagnosis. As you identify such trends, consider how to share them in a meaningful way. Recognizing trends is not only the purview of the OIG.

Speak Your Mind

When you recognize trends, use your knowledge and share it. It may be difficult to find the time because you are expected to code X number of records per day, upon which your productivity is measured. If you have a regular team meeting, tell your supervisor there is something you’d like to discuss. If you don’t have regular meetings, ask to meet with your manager one-to-one.
Go to the OIG website ( and print out the specific text on same-day readmissions. Discuss with your manager the patterns you have noticed. Be prepared with a list of the diagnoses and DRGs you see in the patterns.
Offer to share what you’ve noticed with utilization review, case management, documentation improvement, or any other area in health information management (HIM) compliance that focuses on medically unnecessary or questionable readmissions. Sharing any trends that reflect quality of care can be important to helping improve readmission rates in your facility.

Take the Next Steps

In some facilities, coders work together with documentation improvement nurses. But coders also have value for case management and utilization review because they notice trends of which the nurses may not be aware.
If you can, make copies of the cases supporting the trends to share with the nurses. Remove protected health information, unless there is a reason they need to see it. Even though you work on the “back end” and code same-day readmissions that have already taken place, share that knowledge with those who can affect the current admission status. This is especially important in facilities that repeatedly assign the same care manager to a certain floor or service. This person knows the status of her floor or area, but is likely unaware there is a readmission problem originating in the ED.

Make It a Team Effort

Improvement does not happen in a vacuum. Hospitals, like many businesses, tend to form silos where useful information is not shared. Suggest to your HIM manager to consider assigning a coder to work with the compliance officer, in addition to case management and utilization review.
Each individual discipline brings more useful information to the table for discussion. When the information is shared, strategies emerge that benefit everyone. Perhaps your compliance office would like to know every time there is a case of XYZ discharged within ABC time frame with DRG 000 because she is aware the OIG is requesting that data for a planned audit. Who better to provide that information than a coder?

Barbara Aubry, RN, CPC, CHCQM, FAIHQ, is a senior regulatory analyst at 3M Health Information Systems. She is responsible for analyzing CMS and other payer rules and regulations and communicating how the changes impact 3M customers. Aubry works with development, planning and marketing. She also creates and maintains data and is heavily involved in ICD-10 translation of NCD policies for CMS. Previously, Aubry was utilization review manager at Holy Name Hospital, director of peer review and audit for a privately owned company, and manager of the department of utilization management for an East Coast HMO.
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