Current through Register Vol. 18, September 20, 2024
(1)
The department's APR-DRG prospective payment rate for inpatient hospital
services is based on the classification of inpatient hospital discharges to
APR-DRGs. The provider reimbursement rates for inpatient hospital services,
except as otherwise provided in ARM
37.85.206, is
stated in the department's APR-DRG fee schedule adopted and effective at ARM
37.85.105.
The procedure for determining the APR-DRG prospective payment rate is as
follows:
(a) The department will assign an
APR-DRG to each Medicaid client discharge in accordance with the current
APR-grouper program version, as developed by 3M Health Information Systems. The
assignment and reimbursement of each APR-DRG is based on:
(i) the ICD-9-CM principal diagnoses for
dates of discharge prior to and including September 30, 2015, and the ICD-10-CM
principal diagnoses for dates of discharge October 1, 2015 and
thereafter;
(ii) all ICD-9-CM
secondary diagnoses for dates of discharge prior to and including September 30,
2015, and the ICD-10-CM secondary diagnoses for dates of discharge October 1,
2015 and thereafter;
(iii) all
ICD-9-CM medical procedures performed during the client's hospital stay for
dates of discharge prior to and including September 30, 2015, and the
ICD-10-PCS medical procedures performed during the client's hospital stay for
dates of discharge October 1, 2015 and thereafter;
(iv) the client's age;
(v) the client's gender;
(vi) the client's discharge status;
and
(vii) diagnosis codes related
to hospital-acquired conditions that are not present or undetermined to be
present on admission.
(b) For each APR-DRG, the department
determines a relative weight using a national database from 3M that reflects
the cost of hospital resources used to treat cases. The relative weights have
been recentered so that the average Montana Medicaid stay has a base weight of
1.00. Adjustments are applied to specific APR-DRG weights to reflect department
policy. The relative weight for each APR-DRG is available upon request from
Department of Public Health and Human Services, Health Resources Division, 1400
Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(c) The department computes a Montana average
base price per case. This base price includes in-state and out-of-state
distinct part rehabilitation units. The effective date and base rate amount is
adopted and effective as provided at ARM 37.85.105. Disproportionate share
payments are not included in this price.
(d) The department computes a base price for
long term acute care (LTAC) hospitals. The effective date and base rate amount
is adopted and effective as provided at ARM 37.85.105. Disproportionate share
payments are not included in this price.
(e) The department computes a base price for
Center of Excellence hospitals. The effective date and base rate amount is
adopted and effective as provided at ARM 37.85.105. Disproportionate share
payments are not included in this price.
(f) The relative weight for the assigned
APR-DRG is multiplied by the average base price per case to compute the APR-DRG
prospective payment rate for that Medicaid client discharge.
(g) For claims with dates of payment on or
after August 1, 2011, when a hospital-acquired condition occurs during
hospitalization and the condition was not present or undetermined to be present
on admission, claims will be paid as though the diagnosis is not present or
undetermined to be present. Hospital-acquired conditions refers to the Centers
for Medicare and Medicaid Services (CMS) definition as provided in Section
1886(d)(4) of the Social Security Act.
(h) Inpatient reimbursement will be
calculated at the lesser of the assigned APR-DRG rate or the claim billed
charges.
(2) The
department adopts and incorporates by reference the APR-DRG Table of Weights
and Thresholds adopted and effective at ARM 37.85.105. The Montana Medicaid
APR-DRG relative weight values, average national length of stay (ALOS), outlier
thresholds, and APR-DRG grouper are contained in the APR-DRG Fee Schedule which
is adopted and effective as provided at ARM
37.85.105
and published by the department. Copies may be obtained from the Department of
Public Health and Human Services, Health Resources Division, 1400 Broadway,
P.O. Box 202951, Helena, MT 59620-2951.
AUTH:
2-4-201,
53-2-201,
53-6-113,
MCA; IMP:
2-4-201,
53-2-201,
53-6-101,
53-6-111,
53-6-113,
MCA
