Inpatient Readmission Updates

In alignment with CMS and the National Quality Forum (NQF), beginning September 30th, 2022, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will not allow separate reimbursement for claims identified as an inpatient readmission.  

Inpatient readmissions are defined as inpatient stays at the same hospital within 30 days that represent treatment for the same, similar, or related condition.  Please see Reimbursement Policies for both Commercial and Medicare.

Inpatient readmission criteria may include, but are not limited to:  

• The same or closely related condition or procedure as the prior discharge.  
  
• An infection or other complication of care.  
• A condition or procedure indicative of a failed surgical intervention.  
• An acute decompensation of a coexisting chronic disease.  
• A need that could have reasonably been prevented by the provision of appropriate care consistent with accepted standards in the prior discharge or during the post discharge follow-up period.  
• An issue caused by a premature discharge from the same facility.  

Blue Cross NC may request medical records for the initial and subsequent inpatient stays to review the clinical conditions, treatment and management and determine if the readmission criteria for the subsequent admission exists. 

These changes apply to all commercial, Administrative Services Only (ASO), Blue Medicare and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This change does not apply to Blue Cross NC members who seek care in other states. This change is applicable to facilities reimbursed for inpatient services regardless of payment methodology for Commercial business and Diagnosis Related Groups (DRG) for Medicare business.  

Contractual language and exceptions will supersede this policy criteria.