New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 7 - DIAGNOSIS RELATED GROUPS (DRG)
Section 10:52-7.2 - Calculation of payment rates

Universal Citation: NJ Admin Code 10:52-7.2

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Outliers are patients displaying atypical characteristics relative to other patients in a DRG. The three categories of outliers are defined and the methodology for outlier payment is established as follows.

1. High length of stay: Patients assigned to a DRG, but whose Length of Stay (LOS) is longer than the high LOS trim point.
i. The rate is the inlier rate per case plus a per diem for each acute day from the date of admission to the date of discharge.

2. Low length of stay: Patients assigned to a DRG, but whose Length of Stay (LOS) is shorter than the trim point.
i. Payment is limited to either the lower of the inlier rate per case or the sum of the acute days multiplied by the low per diem.

3. Transfer patients: Patients under medical advice requiring continued acute care who are transferred from one Acute Care Facility to another Acute Care Facility.
i. Where a patient's discharge status is that of a transfer to another acute care facility (inpatient), the rate is limited to the lower of the inlier rate per case or the sum of the acute days multiplied by the low outlier per diem. The hospital which received the transfer patient (and that patient is subsequently a non-transfer status discharge) will receive the appropriate rate per case or per diem based upon DRG assignment and trim point status.

4. The payment rates for DRGs with no base year experience will be calculated using Medicaid Statewide base year costs.

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