Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1. [Repealed, 23 SR 298]
Subp.
2. [Repealed, 23 SR 298]
Subp.
3.
Readmission considered as a second admission.
The medical review agent shall issue a certification number
for a readmission that meets the criteria for medical necessity specified in
part
9505.0530, whether the admitting
and readmitting hospitals are the same or different. The medical record of the
admission must state why the recipient was discharged from the hospital and
what the recipient's medical status was upon discharge, and the medical record
of the readmission must state why the recipient is being readmitted and what
the recipient's medical status is at readmission. Both the admission and the
readmission shall be subject to a retrospective review as provided in part
9505.0520, subpart 10. If the
reason for the discharge and the reason for the readmission meet one set of
circumstances specified in items A to D, the medical review agent shall
determine that both the admission and the readmission shall retain the
certification number subject to the hospitals' and admitting physicians'
compliance with all requirements of parts
9505.0501 to
9505.0545.
A. The readmission results from the recipient
leaving the hospital against medical advice.
B. The readmission results from the recipient
being noncompliant with medical advice that is recorded on the recipient's
medical record as being given to the recipient at the admitting hospital. For
purposes of this part, "recipient being noncompliant with medical advice" means
that the recipient, fully informed of his or her medical condition, and fully
understanding the need for the treatment and the follow-up discharge
instructions, if any, refuses to adhere to the treatment or to follow the
discharge instructions.
C. The
readmission results from a new episode of the same diagnosis of an episodic
illness or condition.
D. The
readmission results from the fact that the recipient's discharge from the
admitting hospital and readmission are medically necessary according to
prevailing medical standards, practice, and usage.
Subp. 4.
Readmission considered as
continuous with admission.
The medical review agent shall determine that a readmission
of a recipient is continuous with the recipient's admission whether the
admitting and readmitting hospitals are the same or different if the
circumstances requiring the recipient's readmission meet one set of the
circumstances specified in items A to C. The medical review agent shall issue a
certification number if the readmission meets the criteria for medical
necessity specified in part
9505.0530. The medical record of
the admission must state why the recipient was discharged from the hospital and
what the recipient's medical status was upon discharge, and the medical record
of the readmission must state why the recipient is being readmitted and what
the recipient's medical status is at readmission. Both the admission and the
readmission are subject to a retrospective review as provided in part
9505.0520, subpart 10. Upon
completing the retrospective review and determining whether the readmission and
admission are consistent with item A, B, or C, the medical review agent shall
take the action specified in the item that applies. Medical assistance payment
for the inpatient hospital services retaining the certification number after
the determination resulting from the retrospective review must be paid
according to parts
9500.1090 to
9500.1140 for the diagnostic
category assigned to the recipient's principal diagnosis of the admission and
readmission. In each circumstance, retention of the certification number is
subject to the hospital's and admitting physician's compliance with all
requirements of parts
9505.0501 to
9505.0545.
A. The recipient was discharged from the
admitting hospital without receiving the procedure or treatment of the
condition diagnosed during the admission because of the hospital's or
physician's preference or because of a scheduling conflict. If the admitting
and readmitting hospitals are the same, the medical review agent shall withdraw
the certification number of the readmission and determine the admission
eligible to retain the certification number. If the admitting and readmitting
hospitals are not the same, the medical review agent shall apply the
requirements under subpart
5, item C, regarding
admission and readmission eligible for a transfer payment.
B. The recipient's discharge was not
appropriate according to prevailing medical standards, practice, and usage. If
the admitting and readmitting hospitals are the same, the medical review agent
shall determine the admission eligible to retain the certification number and
withdraw the certification number of the readmission. If the admitting and
readmitting hospitals are different, the medical review agent shall withdraw
the certification number of the admission and shall determine the readmission
eligible to retain a certification number.
C. The recipient's discharge and readmission
to the same hospital results from the preference of the recipient or the
recipient's family that the recipient's treatment be delayed, that the
recipient be discharged without receiving the necessary procedure or treatment,
and that the recipient be readmitted for the necessary procedure or treatment.
If the admitting and readmitting hospitals are the same, the medical review
agent shall determine the admission eligible to retain the certification number
and withdraw the certification number of the readmission. If the admitting and
readmitting hospitals are not the same, the medical review agent shall apply
the requirements under subpart
5, item A, regarding
admission and readmission eligible for a transfer payment. For purposes of this
part, "preference of the recipient or the recipient's family" means that the
recipient or the recipient's family makes a choice to delay or change the
location of inpatient hospital services, and the choice is compatible with
prevailing medical standards, practices, and usage.
Subp. 5.
Admission and readmission
eligible for transfer payment.
The medical review agent shall issue a certification number
for an admission and readmission that are eligible for a transfer payment if
the admission and readmission meet the criteria for medical necessity specified
in part
9505.0530, and a set of
circumstances in item A, B, or C. The medical record of the admission must
state why the recipient was discharged from the hospital and what the
recipient's medical status was upon discharge, and the medical record of the
readmission must state why the recipient is being readmitted and what the
recipient's medical status is at readmission. The medical review agent shall
conduct a retrospective review of the medical records, determine whether the
admission and readmission are consistent with the circumstances in item A, B,
or C, and take the action specified in the item. Retention of the certification
number by the hospital is also subject to the admitting physician's and
hospital's compliance with all requirements of parts
9505.0501 to
9505.0545.
A. The readmission results from the
preference of the recipient or the recipient's family that the recipient be
discharged from the admitting hospital without receiving the necessary
procedure or treatment and that the recipient be readmitted to a different
hospital to obtain the necessary procedure or treatment. In this case, both
hospitals shall retain their certification numbers subject to the hospitals'
and admitting physicians' compliance with all requirements of parts
9505.0501 to
9505.0545, and medical assistance
payment to each hospital must be made according to the transfer payment
established under part
9500.1128, subpart
2, item D, for the inpatient
hospital services necessary for the recipient's diagnosis and
treatment.
B. The readmission
results from a referral from one hospital to a different hospital because the
recipient's medically necessary treatment was outside the scope of the first
hospital's available inpatient hospital services. In this case, both hospitals
shall retain their certification numbers, and medical assistance payment to
each hospital must be made according to the transfer payment established under
part
9500.1128, subpart
2, item D, for the inpatient
hospital services necessary for the recipient's diagnosis and treatment. If,
however, the admission to the first hospital is not due to an emergency and the
first hospital knew or had reason to know at the time of admission that the
inpatient hospital services that were medically necessary for the recipient's
treatment or condition were outside the scope of the hospital's available
inpatient hospital services and the readmission to another hospital resulted
because of the recipient's need for those services, the first hospital's
certification number will be withdrawn.
C. The readmission results from a physician's
or hospital's scheduling conflict at the admitting hospital. The medical review
agent shall determine both hospitals eligible to retain their certification
numbers. In this case, medical assistance payment to each hospital shall be
made according to the transfer payment established under part
9500.1128, subpart
2, item D, for the inpatient
hospital services necessary for the recipient's diagnosis and
treatment.
Subp. 6.
[Repealed, 23 SR 298]
Statutory Authority: MS s 256.0625;
256.9353;
256.991;
256B.04;
256B.503;
256D.03