25.2.3 Benefits and LimitationsInpatient hospital services include medically necessary items and services ordinarily furnished by a Medicaid hospital or by an approved out-of-state hospital under the direction of a physician for the care and treatment of patients. The Texas Medicaid Program also reimburses for medically necessary services in the outpatient setting to include day surgery and outpatient observation. Services must be medically necessary and are subject to the Texas Medicaid Program's UR requirements. Services must also be billed to TMHP per Medicaid policy and procedures. Inpatient hospital services include the following:
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• Circumstances requiring the mother and newborn to remain in the hospital longer than two days for a routine vaginal delivery or four days for a cesarean section must be documented. Continuation of hospitalization is a benefit for the infant when the mother is required to remain hospitalized for medical reasons and must be documented. If a hospital discharge procedure code (1-99238 or 1-99239) is submitted for reimbursement with the same date of service as an inpatient neonatal critical care procedure code (1-99295 or 1-99296) or a pediatric critical care procedure code (1-99293 or 1-99294), the hospital discharge procedure code is denied and the critical care procedure code is considered for reimbursement. Take-home drugs, self-administered drugs, or personal comfort items are not benefits of the Medicaid program nor THSteps-CCP, except when received by prescription through the Vendor Drug Program. Reimbursement to hospitals for inpatient services is limited to the Medicaid spell of illness. The spell of illness is defined as 30 days of inpatient hospital care, which may accrue intermittently or consecutively. After 30 days of inpatient care is provided, reimbursement for additional inpatient care is not considered until the client has been out of an acute care facility for 60 consecutive days. Exceptions to the spell of illness are the following:
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• Medicaid reimbursement for services cannot exceed the limitations. Reimbursement to acute care hospitals for inpatient services is limited to $200,000 per client, per benefit year (November 1 through October 31). Claims are reviewed retrospectively, and payments exceeding $200,000 are recouped. This limitation does not apply to services related to certain organ transplants or services to THSteps clients when provided through CCP. Note: Dollar or day limitations are not applicable for clients younger than 21 years of age. |
Bed and board in semiprivate accommodations or in an intensive care or coronary care unit including meals, special diets, and general nursing services; and an allowance for bed and board in private accommodations including meals, special diets, and general nursing services up to the hospital's charge for its most prevalent semiprivate accommodations. Bed and board in private accommodations are provided in full if required for medical reasons as certified by the physician. Additionally, the hospital must document the medical necessity for a private room such as the existence of a critical or contagious illness or a condition that could result in disturbance to other patients. This type of information should be included in Block 80 or attached to the claim.
