Health Information Management

Know the coder's role in accurate portrayal of readmission data

HIM-HIPAA Insider, April 6, 2010

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The statistic is striking. Nearly 18% of admissions result in readmissions within 30 days of discharge, accounting for $15 billion in spending, according to the Medicare Payment Advisory Commission. 

This excess spending is perhaps why the House and Senate healthcare reform bills include provisions that would give the Secretary of Health and Human Services the power to reduce payments to hospitals that have relatively high preventable readmission rates for certain conditions. Reforms also will allow the Secretary to establish a pilot program to test bundling payments for an episode of care, combining payment for initial and subsequent hospitalizations.
CMS essentially has been monitoring and withholding payments for same-day readmissions (i.e., when patients return within a 24-hour period) for quite a while. In 2004, it implemented an edit to ensure denial of payment for any subsequent claim for same-day readmission. When readmission occurs on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals must adjust the claim generated by the original stay. They do this by combining the original and subsequent stay onto a single claim, according to Transmittal 266, Change Request 3389, published July 30, 2004. In its 2010 Work Plan, the OIG says it will test the effectiveness of this edit.
These initiatives and others underscore the importance of ensuring accurate data capture and compliant coding, says Mary Ritchie, RHIA, CCS, CCS-P, CPC, vice president of coding and auditing services at MPA Consulting in Long Beach, CA. “The reports patients see come from the coded data, so [the record] has to be coded correctly,” Ritchie explains. ICD-9 codes along with admission and discharge dates help provide clues regarding whether a patient was readmitted for the same condition within a 30-day time frame, she says.
Note: To read more, visit the HCPro Web site. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the April issue of their newsletters.

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