5160-2-02 General provisions: hospital services.

 

 

 

5160-2-02                    General provisions: hospital services.

 

 

 

(A)    The Ohio medicaid program provides payment for medically necessary covered inpatient and outpatient services provided to eligible medicaid recipients by an eligible hospital provider as defined in rule 5101:3-2-01 of the Administrative Code, subject to the provisions of this chapter and Chapter 5101:3-1 of the Administrative Code (relating to general provisions). This rule provides information about the general provisions for covering hospital services.

 

(B)     The following words and terms, when used in this chapter have the following meanings, unless the context clearly indicates otherwise:

 

(1)    "Inpatient" - A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission.

 

(2)    "Inpatient services" - Services which are ordinarily furnished in a hospital as defined in rule 5101:3-2-01 5160-2-01 of the Administrative Code for the care and treatment of inpatients. Inpatient services include all covered services provided to patients during the course of their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by physicians, podiatrists, and dentists. Inpatient hospital services exclude direct-care physician services except as provided in rule 5101:3-4-01 5160-4-01 of the Administrative Code. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room.

 

(3)   "Outpatient" - A patient who is not an inpatient as defined in paragraph (B)(1) of this rule and who receives outpatient services at a hospital or at a hospital's off-site unit which has been extended accreditation by the "Joint Commission of Accreditation of Health Care Organizations," the "American Osteopathic Association" and/or is certified under medicaremedicare. Outpatient includes a patient admitted as an inpatient whose inpatient stay does not extend beyond midnight of the day of admission except in instances when, on the day of admission, a patient dies or is transferred to another inpatient unit within the hospital, to another hospital, or to a state psychiatric facility.

 

(4)     "Outpatient services" - Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5101:3-2-01 5160-2-01 of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5101:3-4-01 5160-4-01 of the Administrative Code.

 

 

 

(5)       "Diagnostic related groups (DRGsDRGs)" - DRGsDRGs are a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources. The grouping logic used to develop relative weights is described in rule 5101:3-2-07.3 5160-2-65 of the Administrative Code. The groupings used to assign cases to a DRGDRG for claims payment are identified in rule 5101:3-2-07.11 5160-2-65 of the Administrative Code.

(6) "Average" is the arithmetic mean obtained by dividing a sum by the number of its observations.

(7) "Geometric mean" is the nth root of the product of n factors.

(8)(6) "Distinct Part Psychiatric unit distinct part" is a distinct part recognized by medicaremedicare.

(9) "Level I nursery" is a nursery unit within a hospital which is registered with and recognized by the Ohio department of health as a level I nursery.

(10) "Level II nursery" is a nursery unit within a hospital which is registered with and recognized by the Ohio department of health as a level II nursery.

(11) "Level III nursery" is a nursery unit within a hospital that is registered with and recognized by the Ohio department of health as a level III nursery.

(12) "Standard deviation" is the square root of the arithmetic mean of the squares of the deviations from the arithmetic mean.

(13)(7) "Principal diagnosis" is the diagnosis established after study to be chiefly responsible for causing the patient's admission to the hospital.

(14)(8) "Medically necessary services" are services as defined in rule 5160-1-01.which are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part or significant pain and discomfort. A medically necessary service must:

(a) Meet accepted standards of medical practice;

(b) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;

(c) Be appropriate to the intensity of service and level of setting;

(d)Provide unique, essential, and appropriate information when used for diagnostic purposes.

(15)(9) Transfer.

A patient is said to be "transferred" when he or she:

(a)    Is moved from one eligible hospital's inpatient or outpatient department, as described in rule 5101:3-2-015160-2-01 of the Administrative Code, to another eligible hospital's inpatient or outpatient department, including state psychiatric facilities.

(b)    Is moved from an eligible hospital to the same hospital's distinct part psychiatric unit. distinct part.

(c)    Is moved to an eligible hospital from the same hospital's distinct part psychiatric unit distinct part.

(16)(10) Readmissions.

For hospitals paid under the department's prospective payment system, a "readmission" is an admission to the same institution within thirty days of discharge.

(17)(11) Discharges.

A patient is said to be "discharged" when he or she:

(a)   Is formally released from a hospital;

(b)   Dies while hospitalized;

(c)     Is  discharged,  within  the  same  hospital,  from  an  acute  care  bed  and

admitted to a bed in a distinct part psychiatric unit

distinct part as

described in paragraph (B)(8) (B) (6) of this rule or is discharged within the same hospital, from a bed in a distinct part psychiatric unit distinct part to an acute care bed. Rule 5101:3-2-07.11 5160-2-65 of the Administrative Code explains the payment methodology for this type of a discharge; or

(d)  Signs himself or herself out against medical advice (AMA).

(18)(12) "Observation services" are those services furnished on a hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate an outpatient's condition or determine the need for possible admission to the hospital as an inpatient.

(C) Billing: All inpatient and outpatient hospital services must be billed in accordance with national uniform billing requirements for hospital facilities (available on http://www.nubc.org/). Appendix A to this rule describes revenue codes that are covered under the medicaid hospital benefit.

Effective:                                                             04/30/2015

Five Year Review (FYR) Dates:                         01/14/2015 and 04/30/2020

CERTIFIED ELECTRONICALLY

Certification

04/15/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           5164.02

Rule Amplifies:                                  5162.03, 5164.02

Prior Effective Dates:                         4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80,

10/1/83(Emer), 12/29/83, 10/1/84, 11/9/84 (Emer),

2/4/85, 7/29/85, 7/3/86, 10/19/87, 4/23/88, 7/1/89,

12/1/89, 7/1/90, 9/3/91 (Emer), 11/10/91, 7/1/92,

7/1/93, 1/20/95, 12/29/95 (Emer), 3/16/96, 8/1/02,

10/1/03, 6/1/04, 10/1/05, 12/6/10