Provider Notice issued 02/08/13

Chapter H-200, Handbook for Hospital Services

Revision to Non-Payment Policy for Provider-Preventable Conditions (PPCs)

Revision to DCFS Contact Information for Consent to Admit

This bulletin revises HFS policy and billing instructions relating to Provider-Preventable Conditions (PPCs). Provider-Preventable Conditions are those conditions or events that are considered reasonably preventable through compliance with evidence-based guidelines. This bulletin also updates Department of Children and Family Services contact information for hospitals to utilize for consent to admit DCFS wards.

At its meeting on August 14, 2012, the Joint Committee on Administrative Rules (JCAR) suspended an emergency amendment to 89 Illinois Administrative Code Section 148.70 that denied payment for an entire inpatient admission if a hospital-acquired condition (HAC) presented during that admission. As a result of discussions with stakeholders, the department has amended the rule language. Effective with admissions on and after July 1, 2012, and until the time that the department implements the All Patient Refined Diagnosis Related Groups (APR-DRG) claim processing system, the department will reduce the payment for the affected admissions by $900.00.

The department is in the process of modifying its payment calculation to include the maximum deduction of $900.00 for these admissions. Once programming has been completed, the department will perform adjustments to reprice claims that were initially paid at $0.00, and will also perform adjustments to reduce the payment for any affected claims that were paid in full after the emergency rule suspension.

The department is also in the process of modifying its payment calculation to assess payment at $0.00 for the entire admission for claims containing specific secondary "E" diagnosis coding identifying Other Provider Preventable Conditions (OPPCs): a wrong surgical procedure performed on a patient; a surgical procedure performed on the wrong patient; or a surgical procedure performed on the wrong body part. Once programming has been completed, the department will perform adjustments to recoup payments for claims that have paid at an amount greater than $0.00.

Claims that contain a HAC and an OPPC will be priced at $0.00.

A claim for an admission that involves a HAC or an OPPC is to be billed as an admission through discharge claim in order for the department to process and price it correctly.

These policies apply to all hospitals, all inpatient claims (including Medicare/Medicaid combination claims), and both the DRG and per diem reimbursement methodologies.

The Handbook for Hospital Services has been updated and is available on the department's Web site. Any questions regarding this bulletin should be directed to your facility's medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

Instructions for updating the Handbook for Hospital Services:

H-262.4 Psychiatric Services

Remove pages HFS H-262 (1-2) and insert new pages HFS H-262 (1-2).

H-262.6 Provider-Preventable Conditions (PPCs)

Remove pages HFS H-262 (3-4) and (5-6) and insert new pages HFS H-262 (3-4) and (5-6).

H-262 Inpatient Services

General inpatient hospital services are defined by the department as those services ordinarily provided by licensed general hospitals, other than those identified inpatient services for which the department has established specific participation requirements. Included in general inpatient services are medical, surgical, pediatric, orthopedic, maternity, intensive care services, etc. Inpatient services provided to a patient during an acute stage of renal disease are also considered to be general inpatient services.

Inpatient services are covered when a patient's medical necessity for services on an inpatient basis are documented (see Topic H 202, Record Requirements). If surgery is performed, the provider must indicate the attending physician and the operating surgeon identification numbers on the institutional claim form. Reimbursement will not be made for services that were billed as acute inpatient care and subsequently denied in the review process as not being medically necessary (see Topic H 266, Utilization Review.)

A hospital's reimbursement for an inpatient stay is all-inclusive. If the hospital finds it necessary to transport a patient to another facility for additional tests or specialized services, the inpatient hospital is responsible for payment to the other facility. The hospital should identify the ancillary services performed at the other facility and show the charges on the inpatient claim billed to the department. The other facility may not bill the department separately for the ancillary services performed at its location.

The day on which a patient begins a leave of absence must be treated as the day of discharge or non certified day and cannot be counted as a covered day unless the patient returns to the hospital prior to midnight of the same day.

The total number of days for which charges can be made cannot exceed the number approved by the appropriate utilization review authority.

H-262.1 Per Diem Reimbursed Care

Charges for inpatient per diem reimbursed care are to be the hospital's usual and customary charges. Payment shall be made based upon calendar days. The day of discharge is not counted. An admission with discharge on the same day is counted as one day. If a patient is admitted, discharged and re admitted on the same day, only one day is counted.

H-262.2 DRG-Reimbursed Care

Charges for DRG-reimbursed inpatient care should be the facility's usual and customary charges. The assignment of a discharge to a DRG will, as appropriate, be based on the patient's age, sex, principal diagnosis, secondary diagnoses, procedures performed, and discharge status. The department utilizes the CMS Medicare DRG Grouper, with modifications deemed appropriate due to the differences in the Medicare and Medicaid patient populations and Illinois Medicaid policy.

H-262.3 Tuberculosis Treatment

Inpatient services necessary for the treatment of tuberculosis are considered to be general inpatient services. However, the department can make payment for such services only when they are provided to a person who is a resident of a county or a jurisdiction that does not levy a special tax for the purpose of providing care for tuberculosis patients. It is the responsibility of the hospital to determine whether such tax levy funds are available to pay for these services prior to submitting a claim to the department. If the tax levy funds are exhausted or only cover certain items, it is the responsibility of the hospital to obtain an official notice from the county and attach it to the UB-04 when it is submitted to the department.

=H-262.4 Psychiatric Services

Effective January 2013

Inpatient psychiatric services are those services provided to patients who are in need of short term acute inpatient hospitalization for active treatment of an emotional or mental disorder. Except as specified below, inpatient services for psychiatric care and treatment are not considered to be general inpatient services and may be provided only by hospitals enrolled for Category of Service 21, Inpatient Hospital Services (Psychiatric).

All inpatient psychiatric services billed as Category of Service 21 are exempt from DRG reimbursement and will be reimbursed at a per diem rate.

Inpatient psychiatric services may be provided by a general hospital or by a psychiatric hospital enrolled with the department for Category of Service 21. Federal Medicaid regulations preclude payment for patients over 20 or under 65 years of age in any Institution for Mental Diseases (IMD). Therefore, inpatient psychiatric services provided by psychiatric hospitals are covered services only for patients ages 65 and over and patients under age 21, or up to age 22 for those receiving these services immediately prior to attaining age 21.

A general care hospital not enrolled for inpatient psychiatric services may provide psychiatric care as a general inpatient service (Category of Service 20) only on an emergency basis for a maximum period of three (3) days. During this period, the hospital must seek placement of the patient in a hospital enrolled to provide psychiatric services. Such services are subject to review by the department or its designated agent.

The department will not reimburse for psychiatric admissions for Department of Children and Family Services (DCFS) wards without a written consent from the DCFS Consent Unit or the Child Intake and Recovery Unit. The DCFS Consent Unit and the Child Intake and Recovery Unit (CIRU) are the only entities authorized to consent for psychiatric admissions of DCFS wards. The DCFS consent form must be placed in the patient's file to document that consent to admit the DCFS ward for inpatient psychiatric services was authorized. A faxed copy of the consent form is acceptable.

The DCFS Consent Unit may be reached during normal business hours, 8:30 a.m. - 4:30 p.m., Monday through Friday at 1-800-828-2179. The Consent Unit fax number is 312-814-7015. The Child Intake and Recovery Unit (CIRU) may be reached after regular business hours, on weekends and holidays at 866-503-0184.

Inpatient psychiatric services are not covered services for adult participants of the Family and Children Assistance program cases in the City of Chicago. Only children eighteen (18) years of age or younger on these cases are covered. Persons nineteen (19) years and older covered under the Family and Child Assistance program are not eligible.

H-262.5 Physical Rehabilitation Services

Physical rehabilitation inpatient services provided to patients during an acute stage of a disabling illness or injury are considered to be general inpatient services. When the acute stage ends and the patient no longer requires acute hospital care but does require comprehensive inpatient physical rehabilitation services, such services may be provided only by hospitals enrolled for Category of Service 22, Inpatient Hospital Services (Physical Rehabilitation).

Payment for inpatient physical rehabilitation services will be made only when provided by a general hospital or a rehabilitation hospital, enrolled with the department for Category of Service 22. All physical rehabilitation services are exempt from DRG reimbursement and will be reimbursed at a per diem rate.

The primary reason for hospitalization is to provide a structured program of comprehensive rehabilitation services, furnished by specialists, to a patient with a major disability for the purpose of habilitating or restoring that person to a realistic maximum level of functioning.

Inpatient physical rehabilitation services are not covered for adult participants of the Family and Children Assistance program cases in the City of Chicago. Only children eighteen (18) years of age or younger on these cases are covered. Persons nineteen (19) years and older covered under the Family and Child Assistance program are not eligible.

=H-262.6 Provider-Preventable Conditions (PPCs)
Effective July 1, 2012
Revised January 2013 Retroactive to July 1, 2012

Provider-preventable conditions are those conditions or events that are considered reasonably preventable through compliance with evidence-based guidelines. The department edits inpatient claims for two categories of PPCs. This policy applies to all hospitals, all inpatient claims (including Medicare/Medicaid combination claims), and both the DRG and per diem reimbursement methodologies:

1. PPCs defined as Hospital-Acquired Conditions (HACs): Beginning May 1, 2008, hospitals were required, for informational purposes only, to code inpatient claims with a Present on Admission (POA) indicator for principal and secondary diagnosis codes billed. Present on admission is defined as a condition that is present at the time the order for inpatient admission occurs. The POA indicator will identify if the condition was introduced after the inpatient admission. Effective with admissions on and after July 1, 2012, the department will reduce each inpatient claim by $900.00 if a designated HAC presented during the inpatient admission. The department's designated list of diagnosis codes or diagnosis/procedure code combinations to be utilized as HACs is on the HFS Medicaid Reimbursement Web page.
   
2. PPCs defined as Other Provider Preventable Conditions (OPPCs): The department will deny payment for claims relating to a wrong surgical procedure performed on a patient; a surgical procedure performed on the wrong patient; or a surgical procedure performed on the wrong body part. Hospitals must submit claims to report these incidents and are instructed to populate the inpatient claims with the following specific supplementary diagnosis codes as appropriate:
   
   • E876.5 – Performance of wrong operation (procedure) on correct patient
   • E876.6 – Performance of operation (procedure) on patient not scheduled for surgery
   • E876.7 – Performance of correct operation (procedure) on wrong side/body part

The above designated E codes may be reported in FL 72; however, they must also be identified in FL 67A-Q.

=H-262.61 Present on Admission Indicator Reporting
Effective July 1, 2012
Revised January 2013 Effective Retroactive to July 1, 2012

Present on admission is defined as a condition that is present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department services, observation, or outpatient surgery, are considered as present on admission.

The department requires hospitals to submit a POA indicator for the principal diagnosis code and every secondary diagnosis code on inpatient hospital claims. This requirement applies to all inpatient services and all hospitals.

For specific coding information refer to the UB-04 Data Specifications Manual or 837I Implementation Guide.

The POA data element on an electronic claim (837I) must be in Loop 2300.