Wiki Inpatient Twice with less than 24 hours Between

[BLeigh511]

Hello All!!

I am hoping someone might have some insight for me. We all know about the 3 day payment window when its outpatient and inpatient but what about when a patient is discharged from a hospital and returns and is readmitted within 22 hours. Both inpatient stays are for the same DRG. Is there a national rule or standard on if they can be billed separately or combined? Anyone have any experience with submitting a similar case to Medicare?

 

[CodingKing]

It may depend on the circumstances but looking at a few payers policies its with 30 days it can fall under the same DRG.

Priority Health - http://www.priorityhealth.com/provi...ayment/services/readmissions/payment-schedule

United Health - https://www.unitedhealthcareonline....ission_Review_Program_Clinical_Guidelines.pdf

HealthPlus of Michigan - https://www.healthplus.org/uploadedFiles/Provider_Manual/DRG Readmissions Within 30 Days.pdf

They seem to all be off the same 30 day timeframe except for Medicaid which appears to nbe 15 days

 

[shannfd]

CMS IOM Medicare Claims Processing Manual - Chapter 3 - Section 40.2.5 - Repeat Admissions
When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.

When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated to, and/or not for evaluation and management of, the prior stay’s medical condition, hospitals shall place condition code (CC) B4 on the claim that contains an admission date equal to the prior admissions discharge date. B4 - Admission Unrelated to Discharge (admission unrelated to discharge on same day)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM3389.pdf