Medicare and some states’ Medicaid programs have specific DRG readmission criteria. A readmission occurs when a patient is discharged/transferred from a hospital, and is readmitted to the same hospital within a day (or days) for symptoms related to, or for evaluation and management of, the prior stay’s medical condition. Most DRG programs require hospitals to adjust the original claim generated by the original stay by combining the original and subsequent stay(s) onto a single claim. DRG readmissions can include more than two claims.

Understanding a Hospital Readmission Reduction Program Audit

It should be noted that DRG readmission denials are not automatic because each federal and state readmission criteria has very specific exceptions.

Medicaid readmission days (time between the discharge and the readmit) vary from state to state. For example, Georgia Medicaid applies 3 days.

Medicare’s DRG Repeat Admission (readmission) policy is more complicated as it includes two different limits; patient readmitted within 24 hours and patient readmitted between 2 through 30 days from date of discharge.

Claims for patients who are readmitted to the same PPS Acute Care facility within 24 hours for the same or related condition, do not require QIO review. “When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals s