Current through Register Vol. 49, No. 9, September, 2024
SECTION II - EPISODES OF CARE
213.000 CONGESTIVE HEART FAILURE (CHF)
EPISODES
213.100 Episode
Definition/Scope of Services
A.
Episode subtypes:
There are no
subtypes for this episode type.
B.
Episode trigger:
Inpatient admission
with a primary diagnosis code for heart failure
C.
Episode
duration:
Episodes begin at inpatient admission for heart
failure. Episodes end at the latter of 30 days after the date of discharge for
the triggering admission or the date of discharge for any inpatient readmission
initiated within 30 days of the initial discharge. Episodes shall not exceed 45
days post-discharge from the triggering admission.
D.
Episode
services:
The episode will include all of the following
services rendered within the episode's duration:
1. Inpatient facility and professional fees
for the initial hospitalization and for all cause readmissions
2. Emergency or observation care
3. Home health services
4. Skilled nursing facility care due to acute
exacerbation of CHF (services not included in episode for patients with SNF
care in 30 days prior to episode start)
5. Durable medical equipment
213.200 Principal
Accountable Provider
The Principal Accountable Provider (PAP) for an episode is the
admitting hospital for the trigger hospitalization.
213.300 Exclusions
Episodes meeting one or more of the following criteria will be
excluded:
A. Beneficiaries do not have
continuous Medicaid enrollment for the duration of the episode
B. Beneficiaries under the age of 18 at the
time of admission
C. Beneficiaries
with any cause inpatient stay in the 30 days prior to the triggering
admission
D. Beneficiaries with any
of the following comorbidities diagnosed in the period beginning 365 days
before the episode start date and concluding on the episode end date:
1) End-Stage Renal Disease;
2) organ transplants;
3) pregnancy;
4) mechanical or left ventricular assist
device (LVAD);
5) intra-aortic
balloon pump (IABP)
E.
Beneficiaries with diagnoses for malignant cancers in the period beginning 365
days before the episode start date and concluding on the episode end date. The
following types of cancers will not be criteria for episode exclusion: colon,
rectum, skin, female breast, cervix uteri, body of uterus, prostate, testes,
bladder, lymph nodes, lymphoid leukemia, monocytic leukemia.
F. Beneficiaries who received a pacemaker or
cardiac defibrillator in 6 months prior to the start of the episode or during
the episode
G. Beneficiaries with
any of the following statuses upon discharge:
1) transferred to acute care or inpatient
psych facility;
2) left against
medical advice;
3)
expired
213.400 Adjustments
No adjustments are included in this episode type.
213.500 Quality Measures
A.
Quality measures "to
pass":1. Percent of
patients with LVSD who are prescribed an ACEI or ARB at hospital discharge -
must meet minimum threshold of 85%.
B.
Quality measures "to
track":1. Frequency of
outpatient follow-ups within 7 and 14 days after discharge
2. For qualitative assessments of left
ventricular ejection fraction (LVEF), proportion of patients matching:
hyperdynamic, normal, mild dysfunction, moderate dysfunction, severe
dysfunction
3. Average quantitative
ejection fraction value
4. 30-day
all cause readmission rate
5.
30-day heart failure readmission rate
6. 30-day outpatient observation care rate -
utilization metric
The following quality measures require providers to submit data
through the provider portal: qualitative assessment of LVEF, average
quantitative ejection fraction value.
213.600
Thresholds for Incentive
PaymentsA. The acceptable threshold is
$6,644.
B. The commendable
threshold is $4,722.
C. The gain
sharing limit is $3,263.
D. The
gain sharing percentage is 50%.
E.
The risk sharing percentage is 50%.
213.700
Minimum Case Volume
The minimum case volume is 5 total cases per 12-month
period.
214.000
TOTAL
JOINT REPLACEMENT EPISODES
214.100
Episode Definition/Scope of
Services
A.
Episode subtypes:
There are no
subtypes for this episode type.
B.
Episode trigger:
A surgical procedure
for total hip replacement or total knee replacement
C.
Episode
duration:
Episodes begin 30 days prior to the date of
admission for the inpatient hospitalization for the total joint replacement
surgery and end 90 days after the date of discharge.
D.
Episode
services:
The following services are included in the
episode:
1. From 30 days prior to the date of
admission to the date of the surgery: All evaluation and management, hip- or
knee-related radiology and all labs/imaging/other outpatient services
2. During the triggering procedure: all
medical, inpatient and outpatient services
3. From the date of the surgery to 30 days
after the date of discharge: All cause readmissions, non-traumatic revisions,
complications, all follow-up evaluation & management, all emergency
services, all home health and therapy, hip/knee radiology and all
labs/imaging/other outpatient procedures
4. From 31 days to 90 days after the date of
discharge: Readmissions due to infections and complications as well as hip or
knee-related follow-up evaluation and management, home health and therapy and
labs/imaging/other outpatient procedures
214.200
Principal Accountable
Provider
For each episode, the Principal Accountable Provider (PAP) is
the orthopedic surgeon performing the total joint replacement procedure.
214.300
Exclusions
Episodes meeting one or more of the following criteria will be
excluded:
A. Beneficiaries who are
under the age of 18 at the time of admission
B. Beneficiaries with the following
comorbidities diagnosed in the period beginning 365 days before the episode
start date and concluding on the date of admission for the joint replacement
surgery:
1) select autoimmune diseases;
2) HIV;
3) End-Stage Renal Disease;
4) liver, kidney, heart, or lung transplants;
5) pregnancy;
6) sickle cell disease;
7) fractures, dislocations, open wounds,
and/or trauma
C.
Beneficiaries with any of the following statuses upon discharge:
1) left against medical advice;
2) expired during hospital stay
D. Beneficiaries who do not have
continuous Medicaid enrollment for the duration of the episode
214.400
Adjustments
For the purposes of determining a PAP's performance, the total
reimbursement attributable to the PAP is adjusted for total joint replacement
episodes involving a knee replacement to reflect that knee replacements have
higher average costs than hip replacements. Overtime, Medicaid may add or
subtract risk or severity factors in line with new research and/or empirical
evidence.
214.500
Quality MeasuresA.
Quality measures "to track":
1. 30-day, all cause readmission
rate
2. Frequency of use of
prophylaxis against post-op Deep Venous Thrombosis (DVtyPulmonary Embolism (PE)
(pharmacologic or mechanical compression)
2. Frequency of post-op DVT/PE
3. 30-day wound infection rate
The following quality measures require providers to submit data
through the provider portal: use of prophylaxis against post-op Deep Venous
Thrombosis (DVT)/Pulmonary Embolism (PE), occurrence of post-op Deep Venous
Thrombosis (DVT)/Pulmonary Embolism (PE)
214.600
Thresholds for
Incentive PaymentsA. The acceptable
threshold is $12,469.
B. The
commendable threshold is $8,098.
C.
The gain sharing limit is $5,249.
D. The gain sharing percentage is
50%.
E. The risk sharing percentage
is 50%.
214.700
Minimum Case Volume
The minimum case volume is 5 total cases per 12-month
period.
ATTACHMENT 4.19-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM STATE
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
-INPATIENT HOSPITAL SERVICES
1.
Inpatient Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY, EFFICIENCY, AND ECONOMY
V.
APPLICATION: Complete details
including technical information regarding specific quality and reporting
metrics, performance thresholds and incentive adjustments are available in the
Episodes of Care Medicaid Manual available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
defined scope of services within the following episode(s) of care are subject
to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
the defined scope of services within the following episode(s) of care are
subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
Episodes
ATTACHMENT 4.19-B
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM STATE
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
-OTHER TYPES OF CARE
2.
a. Outpatient Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
EFFICIENCY, AND ECONOMY V.
APPLICATION:Complete details including technical information
regarding specific quality and reporting metrics, performance thresholds and
incentive adjustments are available in the Episodes of Care Medicaid Manual
available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
defined scope of services within the following episode(s) of care are subject
to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
the defined scope of services within the following episode(s) of care are
subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
Episodes
5. Physicians' Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
EFFICIENCY, AND ECONOMY V.
APPLICATION:Complete details including technical information
regarding specific quality and reporting metrics, performance thresholds and
incentive adjustments are available in the Episodes of Care Medicaid Manual
available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx
and also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
defined scope of services within the following episode(s) of care are subject
to incentive adjustments:
(1)
Acute Ambulatory Upper Respiratory Infection (URI)
Episodes
(2)
Perinatal
Care Episodes
(3)
Attention Deficit Hyperactivity Disorder (ADHD) Episodes
Effective for dates of service on or after February 1, 2013,
the defined scope of services within the following episode(s) of care are
subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
Episodes
23. Any other medical care and any other type
of remedial care recognized under State law, specified by the Secretary.
e. Emergency Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
EFFICIENCY, AND ECONOMY
V.
APPLICATION:Complete details including technical information
regarding specific quality and reporting metrics, performance thresholds and
incentive adjustments are available in the Episodes of Care Medicaid Manual
available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
defined scope of services within the following episode(s) of care are subject
to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
the defined scope of services within the following episode(s) of care are
subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF)
Episodes
f. Critical Access Hospitals (CAH)
A.
INCENTIVES TO IMPROVE CARE QUALITY,
EFFICIENCY, AND ECONOMY
V.
APPLICATION:Complete details including technical information
regarding specific quality and reporting metrics, performance thresholds and
incentive adjustments are available in the Episodes of Care Medicaid Manual
available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
defined scope of services within the following episode(s) of care are subject
to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
the defined scope of services within the following episode(s) of care are
subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF)
Episodes
