Case Management

Is improper billing inflating your readmission rate?

Case Management Monthly, August 1, 2011

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Case Management Monthly.

Hospitals may have a higher than expected readmission rate simply because they aren't properly billing cases that should be a leave of absence. Instead, hospitals are billing them as a new admission, which will trigger a readmission under the new rules, says Kimberly ­Anderwood Hoy, Esq., CPC, director of Medicare and compliance at HCPro, Inc., in Danvers, MA.

There are cases when an inpatient requires a medically necessary procedure but it cannot be scheduled immediately. If the patient does not require inpatient care and is stable enough to return home, the hospital can place the patient on leave of absence, which allows the patient to return home until the hospital can provide the procedure.

The Medicare Claims Processing Manual, Chapter 1, section 40.2.5, explains how providers can use leave of absence:

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. Examples could include, but are not limited to, situations where surgery could not be scheduled immediately, a specific  surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately. Institutional providers may not use the leave of absence billing procedure when the second admission is unexpected.

"The manual clearly says that leave of absence cannot be used to bill an unplanned readmission," says ­Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Case Management Monthly.

Most Popular