Posted 03/15/2023 Updated 06/30/2023
Plesase Note: An updated CPCP027 Inpatient Readmissions was posted 06/30/2023 which includes revisions to verbiage for clarification.
Effective July 1, 2023, we’re updating our existing Clinical Payment and Coding Policy CPCP027 Inpatient Readmissions which utilizes guidance from the Centers for Medicare & Medicaid Services (CMS). Blue Cross and Blue Shield of Texas (BCBSTX) will review claims for readmissions for the number of days specified in the provider’s contract of the initial discharge for the same, similar, or related diagnosis to the same hospital.
In addition, the following sections were updated:
- Review Criteria (formerly Medical Documentation section)
- Claims Review Process
- Claim Adjudication
This list is not exhaustive of all changes to the policy. BCBSTX encourages you to read the entire updated Clinical Payment and Coding CPCPC027 Inpatient Readmissions Policy for more information.
Under this existing and updated BCBSTX policy, 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 BCBSTX determines a provider has submitted a second claim within the number of days specified in the provider contract, after a patient has been discharged from an acute inpatient stay, a post payment audit of the initial admission and subsequent readmission may occur.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
Be sure to check eligibility and benefits before rendering service(s) to make sure a procedure is a covered benefit for the member.
Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.