§ 1163.57. Payment policy for readmissions.
(a) Except as specified in subsection (c), if a recipient is readmitted to a hospital within 30 days of discharge, the Department makes no payment in addition to the hospital’s original DRG payment. If the combined hospital stay qualifies as an outlier, an outlier payment will be made.
(b) If a patient is readmitted within 30 days of discharge for the treatment of conditions that could or should have been treated during the previous admission, the Department makes no payment in addition to the hospital’s original DRG payment.
(c) Except as specified in subsection (b), if a patient is readmitted to the hospital due to complications of the original diagnosis and this results in a different DRG with a higher payment rate, the Department pays the higher DRG payment rate rather than the original DRG rate.
(d) Except as specified in subsection (b), if a patient is readmitted to the hospital due to conditions unrelated to the previous admission, the Department considers the readmission a new admission for payment purposes.
Source The provisions of this § 1163.57 adopted September 23, 1983, effective September 24, 1983, 13 Pa.B. 2881; amended June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended April 13, 2012, effective July 1, 2011, 42 Pa.B. 2023. Immediately preceding text appears at serial page (201298).
Notes of Decisions Hospital was permitted to receive cost of treatment from the Department for a patient who suffered a second heart attack within 7 days of her first admission for a heart attack because the second attack was unrelated to the first and could not have been treated during the initial visit. Windber Hospital, Wheeling Clinic v. Department of Public Welfare, 545 A.2d 452 (Pa. Cmwlth. 1988).
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