Book excerpt: What is a readmission?

Readmissions occur when a patient needs to return to the hospital for additional care within 30-days of their initial stay. The Hospital Readmissions Reduction Program (HRRP) counts those readmissions to an acute care hospital paid under the inpatient prospec­tive payment system (IPPS) from the same or another acute care hospital, with the exceptions of planned, or same-day readmissions for the same condition to the same hospital.

Only admissions with a relevant principal diagnosis counts against the facility’s HRRP index. Additionally, the patient must have been covered with fee-for-service Medicare for a full year prior to and during admission, and the admission must meet all HRRP criteria for inclusion and exclusion (whether complicating conditions contribute to the need for the readmission and are “included” or “excluded” in the HRRP measure) regarding a specific condition. The readmission measure does not incor­porate a rolling 30-day interval. If more than one qualifying admission occurs within 30 days, only the first is included as an index admission.

Although the HRRP and the Inpatient Quality Reporting (IQR) program use essentially the same methods to measure readmissions, the two programs use different sets of hospitals and different measurement periods so the calculations differ.

The HRRP began on October 1, 2012, with a maximum reduction to hospitals with excess readmissions of 2% of base operating payment amounts. This increased to 3% in fiscal year 2015. The Centers for Medicare & Medicaid Services (CMS) began assessing hospitals’ readmission payment adjustments using three risk-standardized, 30-day readmission measures for Medicare beneficiaries endorsed by the National Quality Forum (NQF). The three diagnoses originally chosen for this measure were:

• Myocardial infarction
• Heart failure
• Pneumonia

Chronic obstructive pulmonary disease (COPD) and readmissions following elective primary total hip or knee arthroplasties were added in 2014, in 2015 readmissions after coronary artery bypass surgeries (CABG) was added, and in fiscal year 2016, the cohort of eligible diagnoses related to pneumonia was expanded to include patients with a diagnosis of aspiration pneumonia, and those patients with a principal diagnosis of sepsis and a secondary diagnosis of pneumonia present on admission. However, patients with severe sepsis are excluded from this measure.

Editor’s note: This article is an excerpt from the book The Essential Guide to Supporting Quality Care Measures Through Documentation Improvement.