Current through Register Vol. 24-18, September 15, 2024
(1) Inpatient
services are exempt from the diagnosis-related group (DRG) payment method only
if they qualify for payment methods specifically mentioned in other sections of
this chapter or in this section.
(2) Subject to the restrictions and
limitations in this section, the agency exempts the following services for
medicaid and CHIP clients from the DRG payment method. This policy also applies
to covered services paid through medical care services (MCS) and any other
state-administered program, except when otherwise indicated in this section.
The exempt services are:
(a) Withdrawal
management services when provided in a hospital having a withdrawal management
provider agreement with the agency to perform these services.
(b) Hospital-based intensive inpatient
withdrawal management, medical stabilization, and drug treatment services
provided to substance-using pregnant people (SUPP) clients by an
agency-approved hospital. These are medicaid program services and are not
covered or funded by the agency through MCS or any other state-administered
program.
(c) Acute physical
medicine and rehabilitation (acute PM&R) services.
(d) Psychiatric services. An agency designee
that arranges to pay a hospital directly for psychiatric services may use the
agency's payment methods or contract with the hospital to pay using different
methods.
(e) Chronic pain
management treatment provided in a hospital approved by the agency to provide
that service.
(f) Administrative
day services. The agency pays administrative days for one or more days of a
hospital stay in which an acute inpatient or observation level of care is not
medically necessary, and a lower level of care is appropriate. The
administrative day rate is based on the statewide average daily medicaid
nursing facility rate, which is adjusted annually. The agency may designate
part of a client's stay to be paid an administrative day rate upon review of
the claim or the client's medical record, or both.
(g) Inpatient services recorded on a claim
grouped by the agency to a DRG for which the agency has not published an
all-patient DRG (AP-DRG) or all-patient refined DRG (APR-DRG) relative weight.
The agency will deny payment for claims grouped to APR DRG 955 or APR DRG
956.
(h) Organ transplants that
involve heart, intestine, kidney, liver, lung, allogeneic bone marrow,
autologous bone marrow, pancreas, or simultaneous kidney/pancreas. The agency
pays hospitals for these organ transplants using the ratio of costs-to-charges
(RCC) payment method. The agency maintains a list of DRGs which qualify as
transplants on the agency's website.
11-14-075, recodified as §182-550-4400, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500 and 2005 c 518.
07-14-051, § 388-550-4400, filed 6/28/07, effective 8/1/07. Statutory
Authority:
RCW
74.08.090,
74.09.520. 05-12-022, §
388-550-4400, filed 5/20/05, effective 6/20/05. Statutory Authority:
RCW
74.08.090 and
42 U.S.C.
1395 x(v),
42 C.F.R.
447.271, .11303, and .2652. 01-16-142, §
388-550-4400, filed 7/31/01, effective 8/31/01. Statutory Authority:
RCW
74.08.090,
74.09.730,
74.04.050,
70.01.010,
74.09.200, [74.09.]500,[74.09.]530
and 43.20B.020. 98-01-124, § 388-550-4400, filed 12/18/97, effective
1/18/98.
