Administrative Memos

200117

FROM: Theodore O. Will, Chief Executive Officer
DATE: Aug 06, 2001
SUBJECT: Updated Readmission Reports for Calendar Years 1999 and 2000
IPRO CONTACTS:

Kathy Terry, Ph.D., Senior Director, Data Analysis & Evaluation, Ext. 261

As you know, in the Medicare Sixth Scope of Work as part of the Payment Error Prevention Program (PEPP), PROs are required to implement coding/DRG payment error projects as well as projects relating to inappropriate/unnecessary admissions. Readmission within thirty days was selected as IPRO's first inappropriate/ unnecessary admission project. Selection of this topic area was based, in part, on an OIG report which identified New York State (NYS) as an area with high readmission rates. Therefore, a readmission rate for each hospital was calculated as well as an average NYS Medicare readmission rate. Each hospital readmission rate was compared to the NYS average to identify outliers. IPRO reviewed outlier cases and an aggregate report, presenting baseline review findings, was sent to all NYS Prospective Payment System (PPS) hospitals in April 2001.

The enclosed reports provide updated, hospital-specific readmission rates for Calendar Years (CYs) 1999 and 2000, based upon IPRO's analysis of the Medicare inpatient Prospective Payment System (PPS) claims data. These reports provide detail on your hospital's zero day, one day and two to thirty day readmission rates along with comparison rates for your peer group and NYS. The rates were calculated by dividing the number of cases readmitted within the specified time frames by the number of discharges for that year. Transfers, discharges against medical advice, PPS exempt claims, no pay and managed care cases were excluded from all analyses.

In addition, we have included a hospital-specific case listing of all CY 2000 Medicare admissions where the claims data shows that the patient was readmitted either the same day or the next calendar day. The index admission followed by the readmission are listed. It is strongly suggested that all hospitals review this information and incorporate the results of your assessment into your internal monitoring/corporate compliance plan. At a minimum, we suggest you include a statement as to why/why not case review for a sample of the listed medical records was undertaken, as well as the results of your focused review.

In addition to the above, as a result of this analysis, IPRO recommends that hospitals:

• Conduct routine monitoring of inpatient hospitalizations to ensure that patients meet admission criteria and that medical record documentation reflects this need.
• Conduct routine monitoring of inpatient hospitalizations to ensure that patients are stable at discharge and all discharge planning needs have been addressed.
• Conduct routine monitoring of inpatient readmissions to verify that proper billing methods, (i.e., pass days, readmission vs. transfer, etc.) have been appropriately utilized.

Should you have any questions in regard to this report, please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment or Dr. Kathy Terry.