Readmission within 30 days denial

pam.riddlepam.riddle
in DENIALS & APPEALS

I posted this today in Billing and Claims.   I saw where Dr. Hirsh responded to one on this forum you bill separately and pd separately;  we have received a Preventable re-admission w/i 30 days denial and are trying to find some guidance like we have for same day discharge and readmission if unrelated you can use the B4 condition code and guidelines on how to decide if unrelated if your DRGs and even maybe Principal dx doesn't match but could they still be related?? 

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?

Comments

  • ronaldhirschronaldhirsch
    I hope others will chime in but it is really a manual process to look at readmissions to see if they are related. Some would say that if a patient went home after an admission for pneumonia and their blood pressure was 100/60 and they went home, got dizzy, fell, and broke a hip that the admissions were related. But if the discharge was fine and the patient went home and fell over their dog and fractured their hip, it's unrelated.  

    Now the bigger question is who issued the denial? Many commercial payers simply deny every readmission completely up to a month later There are words to describe their behavior but I cannot use them here. 
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