HEDIS® Tip Sheet

Plan All-Cause Readmissions (PCR)

Line of business: BlueAlliance (Commercial) & BlueAlliance Care+ (Medicaid)

Measure Description

Members 18-64 years of age, the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.

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  • The rate is reported as an observed count of 30-day readmissions over the expected count of 30-day readmissions (O/E Ratio).
    • An O/E Ratio below one indicates there were less 30-Day Readmission than expected while an O/E Ratio greater than one indicates more 30-day Readmissions occurred than were expected.
  • This measure is risk-adjusted and looks at the predicted probability that the patient may have an unplanned acute readmission.
  • This denominator is based on discharges.
  • The patient may be in the measure more than once.
  • Inpatient and observation stays where the discharge date from the first stay and the admission date to the second stay are two or more calendar days apart are considered distinct stays.
  • Includes acute discharges from any type of facility (including behavioral healthcare facilities).
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Best Practices

  • Establish a post-discharge process to track, monitor, and follow-up with patients.
  • Review discharge instructions with patients and ensure a follow-up appointment is scheduled.
  • Consider case management for patients with chronic conditions.
  • Keep some time open on provider schedules for patients who are discharged from the hospital. 
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Admission Exclusions:

  • Hospital stays for the following:
    • The admission date is the same as the discharge date.
    • The member died during the stay.
    • A principal diagnosis of pregnancy on the discharge claim.
    • A principal diagnosis of a condition originating in the perinatal period on the discharge claim.
  • Outliers:
    • Three or more hospital stays between January 1 and December 1 of the measurement year for Commercial members.
    • Four or more hospital stays between January 1 and December 1 of the measurement year for Medicaid Expansion members.

Readmission Exclusions:  

  • Nonacute inpatient stays.
  • Exclude acute hospital admissions with any of the following:
    • A principal diagnosis of pregnancy.
    • A principal diagnosis for a condition originating in the perinatal period.
    • A planned hospital for any of the following:
      • Principal diagnosis of maintenance chemotherapy.
      • Principal diagnosis of rehabilitation.
      • An organ transplant.
      • Potentially planned procedure without a principal acute diagnosis.

General Exclusions:

  • Members in hospice during the measurement year. 

Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.


Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.


HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).