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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook

Inpatient and Outpatient Hospital Services Handbook
Table of Contents
1 General Information 7
1.1 National Drug Codes (NDC) 7
1.2 Medicaid Managed Care Services 7
2 Enrollment 7
2.1 Hospital Eligibility Through Change of Ownership 7
2.1.1 Hospital-based Ambulatory Surgical Center (HASC) Enrollment 8
2.2 Hospital-based Rural Health Clinic Enrollment 8
3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) 8
3.1 General Information 8
3.1.1 Reimbursement Limitations 8
3.1.2 Spell of Illness 9
3.1.3 Take-Home Drugs, Self-Administered Drug, or Personal Comfort Items 9
3.1.4 Services Included in the Inpatient Stay 9
3.2 Services, Benefits, Limitations, and Prior Authorization - Acute Care 10
3.2.1 Bed and Board 10
3.2.2 Hysterectomy Services 11
3.2.3 Maternity Care 11
3.2.3.1 Emergency Coverage 11
3.2.3.2 Mother and Newborn Hospital Stay 11
3.2.3.3 Children’s Health Insurance Program (CHIP) Perinatal Coverage 11
3.2.4 Newborn Care 12
3.2.4.1 Newborn Eligibility 12
3.2.5 Organ and Tissue Transplant Services 13
3.2.5.1 Transplant Facilities 13
3.2.5.1.1 Out-of-state Transplant Facilities 13
3.2.5.2 Transplant Benefits and Limitations 13
3.2.5.3 Prior Authorization for Organ and Transplant Services 14
3.2.5.4 Transplants for Medicare-Eligible Clients 14
3.2.5.5 Experimental or Investigational Services 14
3.2.5.6 Reimbursement for Transplant Services 14
3.2.5.7 Nonsolid Organ Transplants 15
3.2.5.7.1 Inpatient Hospitalization 15
3.3 Services, Benefits, Limitations, and Prior Authorization - Inpatient Rehabilitation Services 15
3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services 16
3.4.1 Enrollment 16
3.4.2 General Information 16
3.4.2.1 Professional Services Rendered in the Inpatient Setting 17
3.4.2.2 Documentation Requirements 17
3.4.2.3 Noncovered Services 17
3.4.2.4 CLIA Certification for Laboratory Services 17
3.4.3 Acute Care Hospital Psychiatric Services 18
3.4.3.1 Prior Authorization Requirements 18
3.4.4 Freestanding and State Psychiatric Facilities 18
3.4.4.1 CCIP Services 18
3.4.4.1.1 Prior Authorization Requirements for Children and Adolescents 18
3.4.4.2 Psychiatric Services for Clients 65 Years of Age and Older 21
3.4.4.3 Reimbursement for Services Rendered in an IMD 21
3.4.4.3.1 Medicare Coinsurance and Deductible Reimbursement 22
3.4.4.4 Providing IMD Client Information to TMHP 22
3.4.5 Medicaid Clinical Criteria for Inpatient Psychiatric Care for Clients 23
3.4.6 Extended Stays 24
3.4.7 Court-Ordered Services 24
3.4.8 Denials 25
3.5 Inpatient Utilization Review 25
3.6 Utilization Review Process 25
3.6.1 Admission Review 26
3.6.1.1 Readmission Review 26
3.6.1.2 Hospital-Based Ambulatory (HASC) Surgical Procedures 26
3.6.1.3 Quality Review 26
3.6.1.4 Diagnosis-Related Group Validation 27
3.6.2 Recommendations to Enhance Compliance with Texas Medicaid Fee-for-Service Hospital Claims Submission 27
3.6.3 Technical Denials (DRG Prospective Payment) 28
3.6.3.1 On-Site Reviews 28
3.6.3.2 Mail-In Reviews 28
3.6.4 Acknowledgment of Penalty Notice 29
3.6.5 Sanctions 29
3.6.6 Utilization Review Appeals 29
3.7 Claims Filing and Reimbursement 29
3.7.1 Medicaid Relationship to Medicare 29
3.7.2 Inpatient Claims Information 30
3.7.3 Inpatient Reimbursement 31
3.7.3.1 Prospective Payment Methodology 31
3.7.3.2 Client Transfers 32
3.7.3.2.1 Admission Dates 32
3.7.3.2.2 Continuous Stays – Client Transfers and Readmissions 33
3.7.3.3 Observation Status to Inpatient Admission 33
3.7.3.4 Outliers 34
3.7.3.4.1 Day Outliers 34
3.7.3.5 Children’s Hospitals 35
3.7.3.6 Potentially Preventable Complications (PPC) and Potentially Preventable
Readmissions (PPR) 36
3.7.3.7 State-owned Teaching Hospitals 36
3.7.3.8 Payment Window Reimbursement Guidelines 36
3.7.3.8.1 Exceptions 37
3.7.3.8.2 Professional and Outpatient Claims for Services Related to the Inpatient Admission 38
3.7.3.8.3 Professional and Outpatient Claims for Services Unrelated to the Inpatient Admission 38
3.7.3.9 Potentially Preventable Readmissions (PPR) 39
3.7.4 Provider Cost and Reporting 39
3.7.5 Third Party Liability 40
4 Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility) 40
4.1 General Information 40
4.1.1 Drugs and Supplies 41
4.1.1.1 Self-Administered Drugs 41
4.1.1.2 Take-Home Drugs and Supplies 41
4.1.2 Outpatient Services Provided Without Charge 41
4.1.3 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 41
4.2 Services, Benefits, Limitations, and Prior Authorization 41
4.2.1 Prior Authorization Requirements 41
4.2.2 Emergency Department Services 41
4.2.2.1 Emergency Department Payment Reductions 43
4.2.3 Day Surgery 43
4.2.3.1 Inpatient Admissions for Day Surgeries 43
4.2.3.2 Complications Following Elective or Scheduled Day Surgeries 44
4.2.3.3 Inpatient Admissions After Day Surgery 45
4.2.3.4 Emergency or Unscheduled Day Surgeries 45
4.2.3.5 Complications Following Emergency or Unscheduled Day Surgery 45
4.2.3.6 Incomplete Day Surgeries 45
4.2.4 Outpatient Observation Room Services 46
4.2.4.1 Direct Outpatient Observation Admission 47
4.2.4.2 Observation Following Emergency Room 47
4.2.4.3 Observation Following Outpatient Day Surgery 48
4.2.4.4 Observation Following Outpatient Diagnostic Testing or Therapeutic Services 48
4.2.4.5 Documentation Requirements for Outpatient Observation 48
4.2.4.6 Reporting Hours of Observation 49
4.2.4.7 Client Status Change 50
4.2.4.8 Inpatient Admission to Outpatient Observation 50
4.2.4.9 Observation Services that are not a benefit 53
4.2.5 Hospital-Based Rural Health Clinic Services 53
4.2.6 * Cardiac Rehabilitation 54
4.2.7 Chemotherapy Administration 56
4.2.8 Colorectal Cancer Screening 57
4.2.8.1 Fecal Occult Blood Tests 57
4.2.8.2 Barium Enemas 57
4.2.8.3 * Sigmoidoscopies 57
4.2.8.4 * Colonoscopies 57
4.2.9 Computed Tomography and Magnetic Resonance Imaging 57
4.2.10 Electrodiagnostic (EDX) Testing 58
4.2.11 Fluocinolone Acetonide 58
4.2.11.1 Prior Authorization for Fluocinolone Acetonide 58
4.2.12 Fetal Nonstress Testing and Contraction Stress Test 59
4.2.13 Hyperbaric Oxygen Therapy (HBOT) 59
4.2.14 Laboratory Services 59
4.2.14.1 Clinical Laboratory Improvement Amendments (CLIA) 60
4.2.15 Lung Volume Reduction Surgery (LVRS) 60
4.2.16 Magnetoencephalography (MEG) Services 61
4.2.17 Neurostimulators 61
4.2.17.1 Prior Authorization for Neurostimulators 61
4.2.18 Occupational and Physical Therapy Services 61
4.2.19 Radiation Therapy Services 61
4.2.19.1 * Radiopharmaceuticals 62
4.2.20 Respiratory Services 63
4.2.20.1 Aerosol Treatment 63
4.2.20.2 * Pentamidine Aerosol 63
4.2.20.3 Diagnostic Testing 63
4.2.20.4 * Pulmonary Function Studies 64
4.2.21 Screening, Brief Intervention, and Referral to Treatment (SBIRT) 64
4.3 Documentation Requirements 64
4.4 Outpatient Utilization Review 64
4.5 Claims Filing and Reimbursement 65
4.5.1 Outpatient Claims Information 65
4.5.2 Outpatient Reimbursement 67
4.5.3 Provider Cost and Reporting 68
4.5.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines 68
4.5.5 Outpatient Hospital Revenue Codes 68
4.5.6 Third Party Liability 75
5 Ambulatory Surgical Center and Hospital Ambulatory Surgical Center 75
5.1 Enrollment 75
5.2 Services, Benefits, Limitations, and Prior Authorization 76
5.2.1 Drugs and Supplies 76
5.2.2 Incomplete Surgical Procedures 76
5.2.3 Complications Following Day Surgery Requiring Outpatient Observation or Inpatient Admission 76
5.2.4 Planned Admission for Day Surgery 76
5.2.5 Cochlear Implants 76
5.2.6 Colorectal Cancer Screening 76
5.2.6.1 Sigmoidoscopies 77
5.2.6.2 * Colonoscopies 77
5.2.7 Dental Therapy Under General Anesthesia 77
5.2.8 Fluocinolone Acetonide 77
5.2.9 Implantable Infusion Pumps 78
5.2.9.1 Prior Authorization for Implantable Infusion Pump 78
5.2.10 Stereotactic Radiosurgery 79
5.2.11 Brachytherapy 79
5.2.12 Neurostimulators 79
5.2.13 Prior Authorization 79
5.2.14 * Gynecological and Reproductive Health and Family Planning Services 79
5.3 Documentation Requirements 80
5.4 Claims Filing and Reimbursement 80
5.4.1 Claims Information 80
5.4.2 Reimbursement 80
5.4.2.1 ASC and HASC Global Services 81
5.4.2.2 NCCI and MUE Guidelines 81
6 Military Hospitals 81
6.1 Military Hospital Enrollment 81
6.2 Services, Benefits, Limitations and Prior Authorization 81
6.2.1 Military Hospital Inpatient Services 81
6.2.2 Military Hospital Outpatient and Physician Services 82
6.2.3 Prior Authorization 82
6.3 Documentation Requirements 83
6.3.1 Documentation for Nursing Facility Admissions 83
6.4 Claims Filing and Reimbursement 83
6.4.1 Military Hospital Claims Information 83
6.4.2 Military Hospital Reimbursement 83
7 Claims Resources 84
8 Contact TMHP 85
9 * Forms 85
10 Claim Form Examples 85
 

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