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10 Things We Don't Know About Looming Readmission Penalties

Cheryl Clark, for HealthLeaders Media, March 29, 2012

7. What is an "Applicable Hospital"?
CMS intends to define this term. For example, might an admission that results in a readmission to a cancer hospital be excluded? 

8.  What is the appeal process?
CMS is considering what aspects of readmission rates sent to hospitals for review prior to public release might be correctable, and will clarify its review and process.

9. What future conditions will be added?
Four additional diagnoses account for 11.7% of all preventable readmissions, about 133,000 a year, according to a 2007 MedPAC report. They are:

The ACA specifies these four categories and others the HHS secretary deems appropriate may be added by FY2015. CMS is expected to signal which ones top their list.

10. How will CMS prevent hospitals from gaming the system?
CMS acknowledges the possibility that some hospitals might try various tactics to avoid excess readmission penalties, such as changing diagnostic codes to avoid identifying patients with AMI, heart failure, pneumonia, "systematic shifting, diversion or delays in care," might put pressure on emergency room staff not to admit patients within the 30-day window.

And although CMS has promised to monitor such practices to "minimize any unintended consequences" it has not explained how frequently or with what tools it intends to do so.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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