Current through Register Vol. 39, No. 6, September 16, 2024
(a) The Department
shall establish the lists of the statewide 100 most frequently reported DRGs,
20 most common outpatient imaging procedures, and 20 most common outpatient
surgical procedures performed in the hospital setting to be used for reporting
the data required in Paragraphs (c) through (e) of this Rule. The lists shall
be determined annually based upon data provided by the certified statewide data
processor. The Department shall make the lists available on its website. The
methodology to be used by the certified statewide data processor for
determining the lists shall be based on the data collected from all licensed
facilities in the State in accordance with
G.S.
131E-214.2 as follows:
(1) the 100 most frequently reported DRGs
shall be based upon all hospital's discharge data that has been assigned a DRG
based on the Centers for Medicare & Medicaid Services grouper for each
patient record, then selecting the top 100 to be provided to the
Department;
(2) the 20 most common
imaging procedures shall be based upon all outpatient data for both hospitals
and ambulatory surgical facilities and represent all occurrences of the
diagnostic radiology imaging codes section of the CPT codes, then selecting the
top 20 to be provided to the Department; and
(3) the 20 most common outpatient surgical
procedures shall be based upon the primary procedure code from the ambulatory
surgical facilities and represent all occurrences of the surgical codes section
of the CPT codes, then selecting the top 20 to be provided to the
Department.
(b)
Information required or reported in Paragraphs (a), (c), (d), and (i) of this
Rule shall be posted on the Department's website at:
http://www.ncdhhs.gov/dhsr/ahc and may be accessed at no cost.
(c) In accordance with
G.S.
131E-214.13, all licensed hospitals shall
report the data required in Paragraph (e) of this Rule related to the statewide
100 most frequently reported DRGs to the certified statewide data processor in
a format provided by the certified statewide processor. Commencing with the
reporting period ending September 30, 2015, an annual data report shall be
submitted that includes all sites operated by the licensed hospital. Each
annual report shall be submitted by the due date of January 1.
(d) In accordance with
G.S.
131E-214.13, all licensed hospitals shall
report the data required in Paragraph (e) of this Rule related to the statewide
20 most common outpatient imaging procedures and the statewide 20 most common
outpatient surgical procedures to the certified statewide data processor in a
format provided by the certified statewide processor. This report shall include
the related primary CPT and HCPCS codes. Commencing with the reporting period
ending September 30, 2015, an annual data report shall be submitted that
includes all sites operated by the licensed hospital. Each annual report shall
be submitted by January 1.
(e) The
reports as described in Paragraphs (c) and (d) of this Rule shall be specific
to each reporting hospital and shall include:
(1) the average gross charge for each DRG,
CPT code, or procedure without a public or private third party payer
source;
(2) the average negotiated
settlement on the amount that will be charged for each DRG, CPT code, or
procedure as required for patients defined in Subparagraph (e)(1) of this Rule.
The average negotiated settlement shall be calculated using the average amount
charged all patients eligible for the hospital's financial assistance policy,
including self-pay patients;
(3)
the amount of Medicaid reimbursement for each DRG, CPT code, or procedure,
including all supplemental payments to and from the hospital;
(4) the amount of Medicare reimbursement for
each DRG, CPT code, or procedure; and
(5) on behalf of patients who are covered by
a Department of Insurance licensed third-party and teachers and State
employees, the lowest, average, and highest amount of payments made for each
DRG, CPT code, or procedure by each of the hospital's top five largest health
insurers.
(A) each hospital shall determine
its five largest health insurers based on the dollar volume of payments
received from those insurers;
(B)
the lowest amount of payment shall be reported as the lowest payment from each
of the five insurers on the DRG, CPT code, or procedure;
(C) the average amount of payment shall be
reported as the arithmetic average of each of the five health insurers payment
amounts;
(D) the highest amount of
payment shall be reported as the highest payment from each of the five insurers
on the DRG, CPT code, or procedure; and
(E) the identity of the top five largest
health insurers shall be redacted prior to submission.
(f) The data reported, as defined
in Paragraphs (c) through (e) of this Rule, shall reflect the payments received
from patients and health insurers for all closed accounts. For the purpose of
this Rule, "closed accounts" are patient accounts with a zero balance at the
end of the data reporting period.
(g) A minimum of three data elements shall be
required for reporting under Paragraphs (c) and (d) of this Rule.
(h) The information submitted in the report
shall be in compliance with the federal Health Insurance Portability and
Accountability Act of 1996, 45 CFR Part 164.
(i) The Department shall provide the location
of each licensed hospital and all specific hospital data reported pursuant to
this Rule on its website. Hospitals shall be grouped by category on the
website. On each quarterly report, hospitals shall determine one category that
most accurately describes the type of facility. The categories are:
(1) "Academic Medical Center Teaching
Hospital," means a hospital as defined in Policy AC-3 of the N.C. State Medical
Facilities Plan. The N.C. State Medical Facilities Plan may be accessed at:
http://www.ncdhhs.gov/dhsr/ncsmfp at no cost.
(2) "Teaching Hospital," means a hospital
that provides medical training to individuals, provided that such educational
programs are accredited by the Accreditation Council for Graduated Medical
Education to receive graduate medical education funds from the Centers for
Medicare & Medicaid Services.
(3) "Community Hospital," means a general
acute hospital that provides diagnostic and medical treatment, either surgical
or nonsurgical, to inpatients with a variety of medical conditions, and that
may provide outpatient services, anatomical pathology services, diagnostic
imaging services, clinical laboratory services, operating room services, and
pharmacy services, that is not defined by the categories listed in this
Subparagraph and Subparagraphs (i)(1), (2), or (5) of this Rule.
(4) "Critical Access Hospital," means a
hospital defined in the Centers for Medicare & Medicaid Services' State
Operations Manual, Chapter 2 - The Certification Process, 2254D - Requirements
for Critical Access Hospitals (Rev. 1, 05-21-04), including all subsequent
updates and revisions. The manual may be accessed at the website:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
at no cost.
(5) "Mental Health
Hospital," means a hospital providing psychiatric services pursuant to
G.S.
131E-176(21).
Authority
G.S.
131E-214.4;
131E-214.13;
Temporary Adoption Eff. December 31, 2014;
Eff. September 30,
2015;
Temporary Amendment Eff. March 31, 2016;
Amended
Eff. January 31, 2017.
