Readmission within 30 days denial
Is there any condition code or process you can perform on a corrected claim to show that an Inpatient readmission within 30 days is not related to the previous Inpatient claim? If they are discharged and re-admitted on the same day you can use the Condition code B4 Admission Unrelated to Discharge on Same Day but I can't find anything to help refute this readmission is related and therefore should be paid appropriately two separate MS-DRGS and the statistic also not counted against the hospital's re-admission rate. Can someone help me find the appropriate workflows and official guidance for these situations of readmission within 30 days?
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First, let's clarify the readmission payment for Medicare pts (not Medicare Advantage). Admitted for 4 days for heart failure, goes home, comes back 3 days later with hip fracture and is admitted. You will get paid full DRGs for both admissions. But the hip fracture admission will go into your numerator for readmissions after a heart failure admission. And that will be used to calculate your penalty for future years.
That said, there are exceptions for planned readmissions like for chemotherapy. But few readmissions are planned.
The key is to ensure that the CDI team is all over every readmission to ensure all conditions are captured so that the "expected" readmission rate is as high as it can be since that penalty looks at the observed v expected to calculate the penalty.