Inpatient Hospital Readmissions

Policy ID: Adm 111

Effective Date: January 01, 2027

Last Reviewed: August 01, 2026

Applies To: Migrated Commercial

This policy applies to inpatient acute care hospitals.

Definitions

Code/Term

Code Description/Term Definition

Clinically Related

A symptom, condition, or complication is considered clinically related to an initial inpatient admission when it is associated with the condition treated during the initial admission, including resulting from a condition treated during the initial admission, representing a complication of the treatment, procedure, or surgery performed during the initial admission, or is a manifestation or progression of the same underlying condition or disease as that which was treated in the initial admission.

Initial Admission

The first inpatient admission. The initial admission discharge date is used to calculate the days between the next admission.

Leave of Absence

A temporary discharge status in which a patient is released from inpatient admission with the expectation of a planned return for follow-up care or elective surgery to the discharging facility or an affiliated facility, where the patient does not require a hospital level of care during such the interim period.

Readmission

An unplanned inpatient admission to the same hospital within fifteen (15) days of discharge from the initial admission or as otherwise defined in the applicable network participation agreement.

Policy Statement

A readmission to the same hospital within 15 days of discharge from the initial admission is subject to review to determine whether the readmission is for the same, similar, or an otherwise clinically related condition to the initial admission. A readmission to the same hospital within 15 days of discharge from the initial admission is subject to review to determine whether the readmission is for the same, similar, or otherwise clincially related condition to the initial admission.

Neither the day of discharge nor the day of admission are counted when determining whether a readmission has occurred.
If the readmission is determined to be the same, similar, or otherwise clinically related to the initial admission, it is considered a continuation of the initial admission and is not separately reimbursable.

Our health plan will not separately reimburse for readmissions determined to be a continuation of the initial admission, and facilities may not retain separate reimbursement for such services.

If the readmission is determined to be for the same, similar, or otherwise clinically related condition to the initial admission, providers must submit a single claim that includes all applicable services (e.g., codes, billed charges, and combined length of stay) for both the initial admission and the readmission.

This policy applies to the following:

Emergent readmissions
Planned readmissions or leave of absence
Post-delivery obstetrical care
Same, similar, or otherwise clinically related readmissions

This policy does not apply to the following:

Transfer from one inpatient stay at an acute care hospital to an inpatient stay at another acute care hospital
Patient discharged from the hospital against medical advice

Patient Discharge Status Codes – If one of following, properly applied, patient discharge status codes is billed on the initial admission, then the readmission is not subject to this policy.
- 02 – Discharged/transferred to a Short-Term General
- 05 – Discharged/transferred to a Designated Cancer Center or Children’s Hospital
- 07 – Left against medical advice or discontinued care
- 43 – Discharged/transferred to a Federal Health Care Facility
- 65 – Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital
- 66 – Discharged/transferred to a Critical Access Hospital (CAH)
- 70 – Discharged/transferred to another Type of Healthcare Institution not Defined
- 82 – Discharge/Transfer to a Short-Term General Hospital for Inpatient Care with a Planned Acute Care Hospital Inpatient Readmission
- 85 – Discharged/Transferred to a Designated Cancer Center or Children’s Hospital with a Planned Acute Care Hospital Inpatient Readmission
- 88 – Discharged/Transferred to a Federal Health Care Facility with a Planned Acute Care Hospital Inpatient Readmission
- 93 – Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital with a Planned Acute Care Hospital Inpatient Readmission
- 94 – Discharged/Transferred to a Critical Access Hospital (CAH) with a Planned Acute Care Hospital Inpatient Readmission
- 95 – Discharged/Transferred to Another Type of Health Care Institution Not Defined Elsewhere in this Code List with a Planned Acute Care Hospital Inpatient Readmission

Planned readmissions for cancer chemotherapy, transfusion for chronic anemia, or other similar repetitive treatments
Readmission for unrelated condition
Readmission for the medical treatment of rehabilitation care
Readmission for pre-delivery obstetrical care
Psychiatric and substance abuse
Transplants

Guidelines for Bundling Admissions (not an all inclusive list)

Description of discharge

Billing

Additional Information

Member leaves against medical advice and requires subsequent readmission

Bill the admissions separately

Any discharge of a member against medical advice is considered a regular discharge and the admissions will not be bundled. The hospital record should show that the member signed out against medical advice. Examples include:

Physician writes “discharged AMA” in physician orders.
Member signs AMA form when leaving facility.
Progress notes (by either a physician or a nurse) include written notation indicating that the member left AMA.

Member requests discharge because of uncertainty about undergoing further treatment

Bill the admissions separately if the hospital record shows the member initiated the interruption

The readmission is considered separate if the member needs to return home or requests time to make a major health care decision. Documentation should indicate the patient initiated the discharge.

Member is discharged to allow time to normalize clotting times prior to surgical intervention. After clotting times normalize the patient will be readmitted for surgical intervention

Combine the claims if readmission occurs within 15 days

Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period.

Member meets discharge criteria and has an appropriate discharge plan but requires readmission due to an unrelated condition or a new occurrence of the same condition

Bill the admissions separately

The hospital record must include a discharge plan that is appropriate and reasonable and that addresses the member’s ability to follow the treatment plan after discharge.

Member is discharged with a documented plan for readmission for additional services within an appropriate time frame, based on the member’s benefits or the provider’s request

Combine the admissions as a planned readmission

The care rendered during the subsequent admission was anticipated. Hospitals may place a patient on a leave of absence when readmission is expected.

Example: The member is discharged from hospital because, perhaps, the surgeon is away or the operating room is booked until the following week.

Member is discharged after surgery but is readmitted within 14 days with a direct or related complication from the surgery

Combine the admissions

The monitoring, evaluation and treatment of the member for a known sequel or for common complications following surgery are an expected part of the postoperative period of the first admission.

Example: The member returns in three to five days with a wound infection that requires intravenous antibiotics.

Readmission Billing guidelines

The following applies to inpatient readmission claims that are not listed in the Exclusions/Exemptions section above.

If a member discharges from a hospital and an unplanned readmission occurs within 15 days for a clinically related condition, the prior inpatient admission claim must be adjusted to include the unplanned readmission days.
If a member discharges from a hospital and a planned readmission occurs within 15 days for a clinically related condition:
- Submit only one inpatient claim combining the stays
- Report a leave of absence (LOA) for the days the patient was not at the hospital.
  - Report occurrence code 74 for the LOA day(s)
  - Report revenue code 018X and units equal to the number of LOA days.
- If original discharge and readmission occur within 15 days for a clinically unrelated condition:
  - Submit both inpatient claims separately.
  - Append a B4 (Admission Unrelated to Discharge on the Same Day) condition code on the readmission claim.

Cross References

Adm 129 – Correct Coding Guidelines

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

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