Q&A: Coding for two unrelated admissions within 30 days
Q: Is there a condition code or process we can perform on a corrected claim to show that an inpatient readmission within 30 days is not related to the previous inpatient claim? If a patient is discharged and re-admitted on the same day we can use the Condition Code B4 Admission Unrelated to Discharge on Same Day, but I cannot find anything to help refute that this readmission is related and therefore should be paid appropriately as two separate MS-DRGS. Can someone help me find the appropriate workflows and official guidance for these situations of readmission within 30 days?
A: First, let's clarify the readmission payment for Medicare patients (not Medicare Advantage). For example, a patient is admitted for four days for heart failure, goes home, and comes back three 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 make sure 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-versus-expected to calculate the penalty.
Editors note: This question appeared in the NAHRI Forum and was answered by Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP.