Readmission Review

The NYCHSRO/MedReview Readmission review program involves admission to an acute short-term hospital occurring less than 15 calendar days from the date of discharge from the same or another acute short term hospital.

WHAT IT IS:

  • Readmissions may be indicative of premature discharge or poor quality of care in the first admission. Payments can be affected.

  • Transfers are identified by the code entered on the bill and entries in the medical record.

HOW IT WORKS:

  • Obtain the appropriate medical records for the initial admission and the readmission

  • Perform case review on both stays

  • Analyze the cases specifically to determine whether the patient was prematurely discharged from the first confinement, thus causing readmission

  • Identify the nature of the premature discharge finding as follows:

    • Clinical condition – Patient was discharged even though he/she should have remained in the hospital for further treatment

    • Delayed care – Patient was discharged without having received care that should have been provided during the stay and unnecessarily led to a readmission

    • Level of care – Patient needs to be readmitted but not to the acute care part of the hospital

  • Consider the information available to the attending physician who discharged the patient from the first confinement

  • If single payment criteria apply, NYCHSRO/MedReview:

    • Recodes and reprices claims with all diagnoses and procedures from both claims into one single DRG and one single DRG payment

    • Compares total payment of each DRG to payment of single payment DRG and chooses whichever payment is lowest

    • Notifies provider of overpayment if revised DRG is lower

For more information, click here.