March 30, 2023
We’re updating our existing Inpatient Readmissions Clinical Payment and Coding Policy (CPCP027) that utilizes guidance from the Centers for Medicare & Medicaid Services (CMS). Effective for dates of service on or after July 1, 2023, Blue Cross and Blue Shield of Illinois (BCBSIL) will review acute hospital claims for some commercial members to determine if readmissions to the same facility within 30 days of discharge (or the number of days specified in the provider contract) are related.
Under this existing and updated BCBSIL policy:
- If BCBSIL determines a provider has submitted a second claim within 30 days after a patient has been discharged from an acute inpatient stay, a post-payment audit of the initial admission and subsequent readmission may occur.
- Reimbursement may be denied or reduced for an inpatient readmission if we determine the services rendered are considered a continuation of the initial treatment.
What should I expect?
If a member is readmitted within 30 days, we may ask you to send a corrected claim to confirm diagnosis for the readmission.