Current through Register Vol. 18, September 20, 2024
(1) All
readmissions occurring within 30 days will be subject to review to determine
whether additional payment as a new APR-DRG or as an outlier is warranted. As a
result of the readmission review, the following payment changes will be made:
(a) If it is determined that complications
have arisen because of premature discharge and/or other treatment errors, then
the APR-DRG payment for the first admission must be altered by combining the
two admissions into one for payment purposes.
(b) If it is determined that the readmission
is for the treatment of conditions that could or should have been treated
during the previous admission, the department will combine the two admissions
into one for payment purposes.
(c)
A client readmission occurring in an inpatient rehabilitation hospital or a
rehabilitation distinct part unit three days after the initial date of
discharge must be combined into one admission for payment purposes, with the
exception of discharge to an acute care hospital for surgical
APR-DRGs.
(d) Inpatient
readmissions within 24 hours of discharge must be combined if the same
condition is diagnosed.
(e)
Services that are performed at a second hospital because the services are not
available at the first hospital (e.g., a CT scan) are included in the first
hospital's payment. This includes transportation to the second hospital and
back to the first hospital. Arrangement for payment to the transportation
provider and the second hospital where the services were actually performed
must be between the first and second hospital and the transportation provider.
(2) A transfer, for the
purpose of this rule, is limited to those instances in which a client is
transferred for continuation of medical treatment between two hospitals or
distinct part units, one of which is paid under the Montana Medicaid
prospective payment system.
(a) A
transferring hospital or distinct part unit reimbursed under the APR-DRG
prospective payment system is paid for the services and items provided to the
transferred recipient, the lesser of:
(i) a
per diem rate of two times the average per diem amount for the first inpatient
day plus one per diem payment for each subsequent day of inpatient care. The
per diem payment is determined by dividing the sum of the APR-DRG payment for
the case as computed in ARM
37.86.2907
by the national average length of stay for the DRG. Outlier and add-on payments
are then added if applicable after the transfer payment is computed;
or
(ii) the sum of the APR-DRG
payment for the case as computed in ARM
37.86.2907
and the appropriate outlier, and add-ons, if applicable, as computed in ARM
37.86.2916,
and
37.86.2925.
(b) A discharging
hospital or distinct part unit (i.e., the hospital to which the recipient is
transferred) reimbursed under ARM
37.86.2907
is paid the full APR-DRG payment plus any appropriate outliers and add-ons, if
applicable.
(3)
Outpatient hospital services, including emergency room services and diagnostics
services (including clinical diagnostic laboratory tests) that are provided by
an entity owned or operated by the hospital and occur the day of or the day
before the inpatient hospital admission are deemed to be inpatient services and
must be bundled into the inpatient claim.
(4) A hospital or distinct part unit
reimbursed under the APR-DRG prospective payment system is paid for the
services and items provided to a recipient who is eligible for only part of the
inpatient stay, the lesser of:
(a) a rate of
one per diem payment for each eligible day of inpatient care. The per diem
payment is determined by dividing the sum of the APR-DRG payment for the case
as computed in ARM
37.86.2907
plus outlier if applicable, by the national average length of stay for the DRG.
Add-on payments are then added if applicable; or
(b) the sum of the APR-DRG payment for the
case as computed in ARM
37.86.2907
and the appropriate outlier and add-ons, if applicable, as computed in ARM
37.86.2916
and 37.86.2925.
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
