Combining admissions
A Medicare patient is admitted inpatient for 4 days with pneumonia. Discharged to home on day 5 at 4 pm. Returns to the ED at the same hospital on the next calendar day at 7 am with shortness of breath. Admitted inpatient as pulse oximetry is low and xray worse. Ends up staying another 4 days. Review of previous admission records shows that on day 5 of the first admission the patient had a chest xray that was worse and she should not have been discharged. (But it happened and will be investigated.) So, the readmission was preventable and the hospital knows it was their fault.
So how is this scenario billed? I see four options.
1- The hospital bills one full admission using the leave of absence/planned readmission regulations with value code 81 and OSC 74 encompassing the whole time period of both admissions. As per Chapter 3 of the claims processing manual section 40.2.5
a. This is what the hospital wants to do but since the readmission was not planned they are hesitant to use it
2- The hospital bills the first admission as usual but submits the second admission as a 110 claim and gets no money at all but this allows the admission is registered in the CWF.
a. This is second choice- the hospital wants to record the service in the CWF and since they cannot combine at least they can submit a no pay claim
3- The hospital bills both admissions as normal inpatient admissions and gets the full DRG for both admissions.
a. This is the strict interpretation of the regulation. But the hospital does not really want to accept two DRGs since they are at fault for causing the second admission even though they will lose some money since the readmission will count in the penalty for the next three years.
4- The hospital bills the first admission as usual but submits no claim at all for the second admission.
a. This seems wrong- there needs to be some record of the care in the CWF.What do you all think?