Transcription
Inpatient Hospital ServicesWashington Apple Health (Medicaid)Inpatient HospitalServicesBilling GuideJanuary 1, 2018Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between thisdocument and an agency rule arises, the agency rules apply.
Inpatient Hospital ServicesAbout this guide This publication takes effect January 1, 2018, and supersedes earlier guides to this program.HCA is committed to providing equal access to our services. If you need an accommodation orrequire documents in another format, please call 1-800-562-3022. People who have hearing orspeech disabilities, please call 711 for relay services.Washington Apple Health means the public health insurance programs for eligibleWashington residents. Washington Apple Health is the name used in WashingtonState for Medicaid, the children's health insurance program (CHIP), and stateonly funded health care programs. Washington Apple Health is administered bythe Washington State Health Care Authority.Refer also to the agency’s ProviderOne Billing and Resource Guide for valuable information tohelp you conduct business with the agency.Services and equipment related to any of the following programs must be billed using theirspecific billing instructions: Acute Physical Medicine & Rehabilitation (PM&R)Ambulance and Involuntary Treatment Act TransportationLong Term Acute Care (LTAC)Outpatient Hospital ServicesPhysician-Related Services/Health Care Professional ServicesThis publication is a billing instruction.2
Inpatient Hospital ServicesWhere can I download agency forms?To download an agency provider form, go to HCA’s Billers and provider’s webpage, selectForms & publications. Type the HCA form number into the Search box as shown below(Example: 13-835).What has changed?SubjectClient EligibilityChangeThis section is reformatted andconsolidated for clarity and hyperlinkshave been updated.Reason for ChangeHousekeeping andnotification of newregion moving to FIMCEffective January 1, 2018, the agencyis implementing another FIMC region,known as the North Central region,which includes Douglas, Chelan, andGrant Counties.Billing for plannedreadmissionsUnbundlingRemoved specific date information inreference to billing for plannedreadmissions.Added a new section to provideexamples of services that the agencydoes not pay separately. These servicesconsidered part of the “bundledservices” under the diagnosis codebilled on the claim.3ClarificationClarification
Inpatient Hospital ServicesSubjectChangeReason for ChangeUpdated MID criteria to include thatthe MID stay cannot be a scheduledadmission and that the MID stay is amedical stay and not a psychiatricstay.Updated the information about addingthe covered 3 or 5 days and theauthorized extension days to thecovered column on the claim.ClarificationVentricular assistdevice (VAD) andpercutaneousventricular assistdevice (PVAD)servicesRenamed the section (formerlyVentricular assist device (VAD)services). Updated the section toremove specific information andreference the Physician-RelatedServices/Health Care ProfessionalServices Billing Guide.Clarification andstreamliningTranscatheter aorticvalve replacement(TAVR)Hospital dispute andappeal processAdded that the NPI for each teamsurgeon must be provided for payment.ClarificationRemoved the addresses and faxnumbers for sending disputes andappeals. Providers receive thisinformation when they are notified ofan adverse determination by the agencyor the agency’s designee.Outdated informationNewborn eligibilityand billingUpdated the title of the section(formerly titled Newborn on mother’sID) and added a crosswalk to determinewhich program the infant is eligible toparticipate in.ClarificationWhat are the MIDcriteria?For MID claimspaid using the CPEpayment method4Correction
Inpatient Hospital ServicesTable of ContentsAbout this guide .2Where can I download agency forms? .3What has changed? .3Table of Contents .5Resources Available .9Definitions .10Client Eligibility .23How do I verify a client’s eligibility? .23Are clients enrolled in an agency-contracted managed care organization (MCO)eligible? .24Managed care enrollment .25Behavioral Health Organization (BHO) .25Fully Integrated Managed Care (FIMC) .26Apple Health Foster Care (AHFC) .27Payment for Services .28How do I get paid? .28Payment adjustments .28General payment policies .29Transfers .29Inpatient hospital psychiatric transfers .30Potentially preventable readmissions prospective reimbursement policy .30Billing for planned readmissions .32What are the agency’s payment methods? .33What are the agency’s payment methods for state-administered programs? .34Diagnosis related group (DRG) payment method (Inpatient primary paymentmethod) .35Validation of DRG assignment .36Valid DRG codes .36DRG relative weights .36DRG conversion factors .37High outliers (DRG) .37Qualifying for high outlier payment using DRG payment method .37Calculating Medicaid high outlier payment .38Calculating state-only-funded program high outlier for state administered program(SAP) claims .38Transfer information for DRG payment method .39Per diem payment method .40Services paid using the per diem payment method .40Hospitals paid using the per diem payment method .41Transfers (per diem) .41Alert! This Table of Contents is automated. Click on a page number to go directly to the page.5
Inpatient Hospital ServicesSingle case rate (bariatric) payment method .42Fixed per diem payment method – (LTAC) .42Transfers (per diem - LTAC) .42Ratio of costs-to-charges (RCC) payment method .43Hospitals paid using the RCC payment method .43Certified public expenditure (CPE) .43Payment for services provided to clients eligible for Medicare and Medicaid.44Recoupment of payments .44Noted Exceptions .44Program Limitations .45Medical necessity .45Unbundling .45Routine supplies .45Components of room and board .46Lab and pharmacy services .46Equipment .46Respiratory therapy .47Specific items/services not covered. .47Administrative days .48Rate guideline for new hospitals .48Psychiatric services .49Major trauma services .49Increased payments for major trauma care .49How does a hospital qualify for TCF payments from the agency?.50TCF payments to hospitals for transferred trauma cases .50TCF payment calculation .51Cap on TCF payments .51Use appropriate condition codes when billing for qualified trauma cases .52Contacts.53Authorization.54General authorization .54Changes in authorization requirements for selected surgical procedures .55“Write or fax” PA .55How does the agency approve or deny PA requests? .56Expedited prior authorization (EPA) .57Surgical policies .57Authorization requirements for surgical procedures.57Surgical procedures that require a medical necessity review by the agency .57Transgender health services .57Surgical procedures that require a medical necessity review by Qualis Health .58Breast Surgeries .59Deliveries .59Agency-approved bariatric hospitals and associated clinics .60Acute physical medicine and rehabilitation (PM&R).60Alert! This Table of Contents is automated. Click on a page number to go directly to the page.6
Inpatient Hospital ServicesLong-term acute care (LTAC) .61Out-of-state hospital admissions (does not include hospitals in designated borderingcities) .61Out-of-country hospital admissions .62Hospitals approved for detoxification services through the Division of BehavioralHealth and Recovery (DBHR) .62Chemical-using pregnant (CUP) women .62Medical inpatient detoxification (MID) services .63What are the MID criteria? .63What is MID authorization?.64What authorization number is used when billing for MID? .64What is the agency’s allowed length of stay (LOS) for MID claims? .64How do I bill the agency for MID services exceeding the 3 or 5 day LOSlimitation? .65Payment methods .67For MID claims paid using the per diem payment method .67For MID claims paid using the CPE payment method .67Agency-approved centers of excellence (COE) .67Experimental transplant procedures .68Payment limitations .69Ventricular assist device (VAD) and percutaneous ventricular assist device (PVAD)services .69Transcatheter aortic valve replacement (TAVR) .70Utilization Review .71What is utilization review (UR)? .71Agency program integrity retrospective UR .72Changes in admission status .72What is admission status? .72When is a change in admission status required? .73Change from inpatient to outpatient observation admission status .73Change from outpatient observation to inpatient admission status .74Change from inpatient or outpatient observation to outpatient admission status .74Change from outpatient surgery/procedure to outpatient observation or inpatientadmission status .75Acute care transfers.75Coding and DRG validations .75DRG outliers .76Length-of-stay (LOS) reviews .76Provider preventable conditions (PPCs) .77Medical record requests for retrospective UR .77Hospital-issued notice of noncoverage (HINN) .78Hospital dispute and appeal process .79Alert! This Table of Contents is automated. Click on a page number to go directly to the page.7
Inpatient Hospital ServicesGeneral Billing .80What are the general billing requirements? .80How do I bill for clients who are eligible for only a part of the hospital stay? .80How are outpatient hospital services prior to admission paid?.82How are outpatient hospital services during an inpatient admission paid? .82How do I bill for neonates/newborns? .82Neonatal/newborn coding .82Birth weight coding.83Newborn eligibility and billing .83Neonate revenue code descriptions .86How do I bill for immediate postpartum long acting reversible contraception(LARC)? .88Submitting adjustments to a paid inpatient hospital claim .89Present on admission indicators .89How to indicate a POA on a direct data entry claim.90How to indicate a POA on an electronic claim .90Billing Specific to Hospital Services .91Interim billing .91Inpatient hospital stays without room charges .91How do I bill for administrative days? .91Billing acute inpatient stay when client elects hospice .93How do effective dates for procedure and/or diagnosis codes affect processing of myclaims? .93How do I bill for clients covered by Medicare Part B only (No Part A), or hasexhausted Medicare Part A benefits prior to the stay? .94What the agency pays the hospital: .94How do I bill for clients when Medicare coverage begins during an inpatient stay orMedicare Part A has been exhausted during the stay? .95Required consent forms for hysterectomies .96Completing the Claim .97How do I bill claims electronically? .97What does the agency require from the provider-generated explanation ofMedicare benefit (EOMB) to process a claim?.97Specific instructions for Medicare crossover claims .98How do I submit institutional services on a crossover claim? .98How do I submit institutional services for inpatient clients who are eligible forMedicare Part B Benefits but not eligible for Medicare Part A Benefits orMedicare Part A benefits are exhausted? .98Alert! This Table of Contents is automated. Click on a page number to go directly to the page.8
Inpatient Hospital ServicesResources AvailableTopicResource InformationSubstance Use Disorderservice providersDirectory of Certified Chemical Dependency Services inWashington StateDivision of BehavioralHealth and Recovery(DBHR)-certifiedhospitalsSee DBHR’s Pregnant Women Chemical Dependency/AbuseResource Guide on the Division of Social and Human Services’(DSHS’s) Substance Use Treatment Services webpage.Contacts for:DBHR’s BehavioralHealth Organizations Psychiatric HospitalizationServices InformationPregnancy ServicesSee the agency’s Pregnancy Services webpage.SterilizationSee the agency’s Sterilization Supplemental ProviderGuide.Additional Medicaidagency resourcesSee the agency’s ProviderOne Resources webpage.9
Inpatient Hospital ServicesDefinitionsThis section defines terms and abbreviations, including acronyms, used in this billing guide.Refer to Chapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Acute – A medical condition of severeintensity with sudden onset. For thepurposes of the acute physical medicine andrehabilitation (Acute PM&R) program,acute means an intense medical episode, notlonger than three months.(WAC 182-550-1050)Administrative day rate - The statewideMedicaid average daily nursing facility rateas determined by the agency. (WAC 182550-1050)All-Patient DRG Grouper (AP-DRG) - Acomputer software program that determinesthe medical and surgical diagnosis relatedgroup (DRG) assignments used by theagency for inpatient admissions betweenAugust 1, 2007, and June 30, 2014. (WAC182-550-1050)Acute care - Care provided for patients whoare not medically stable or have not attaineda satisfactory level of rehabilitation. Thesepatients require frequent monitoring by ahealth care professional in order to maintaintheir health status. Refer to WAC 248-27015. (WAC 182-550-1050)All-Patient Refined DRG Grouper (APRDRG) - A computer software program thatdetermines the medical and surgicaldiagnosis related group (DRG) assignmentsused by the agency for inpatient admissionson and after July 1, 2014.Acute physical medicine andrehabilitation (Acute PM&R) - Acomprehensive inpatient rehabilitativeprogram coordinated by an interdisciplinaryteam at an agency-approved rehabilitationfacility. The program provides 24-hourspecialized nursing services and an intenselevel of therapy for specific medicalconditions for which the client showssignificant potential for functionalimprovement. Acute PM&R is a 24-hourinpatient comprehensive program ofintegrated medical and rehabilitativeservices provided during the acute phase ofa client's rehabilitation. (WAC 182-5501050)Allowable - The calculated amount forpayment, after exclusion of any "nonallowedservice or charge," based on the applicablepayment method before final adjustments,deductions, and add-ons. (WAC 182-5501050)Allowed amount - The initial calculatedamount for any procedure or service, afterexclusion of any "nonallowed service orcharge," that the agency allows as the basisfor payment computation before finaladjustments, deductions, and add-ons.(WAC 182-550-1050)Administrative day – One or more days ofa hospital stay in which an acute inpatient orobservation level of care is not medicallynecessary, and a lower level of care isappropriate. (WAC 182-550-1050)Allowed charges – The total billed chargesfor allowable services. (WAC 182-5501050)10
Inpatient Hospital ServicesAllowed covered charges – The total billedcharges for allowable services minus thebilled charges for noncovered services.(WAC 182-550-1050)Audit - An assessment, evaluation,examination, or investigation of a healthcare provider's accounts, books and records,including both of the following:Ancillary services - Additional or supportingservices provided by a hospital to a clientduring the client’s hospital stay. Theseservices include, but are not limited to, all ofthe following: LaboratoryRadiologyDrugsDelivery roomOperating roomPostoperative recovery roomsOther special items and services(WAC 182-550-1050) Appropriate level of care - The level ofcare required to best manage a client'sillness or injury based on either of thefollowing: Health, financial and billing recordspertaining to billed services paid bythe agency through WashingtonApple Health by a person notemployed or affiliated with theprovider, for the purpose of verifyingthe service was provided as billedand was allowable under programregulationsHealth, financial, and statisticalrecords, including mathematicalcomputations and special studiesconducted in support of the Medicarecost report (Form 2552-96 and 255210 or successor form), submitted tothe agency for the purpose ofestablishing program rates forpayment to hospital providers(WAC 182-550-1050)Authorization – See Prior authorizationand Expedited prior authorization (EPA).(WAC 182-550-1050)The severity of illness presentationand the intensity of servicesreceivedA condition-specific episode of care(WAC 182-550-1050)Authorization number - A nine-digitnumber, assigned by the agency thatidentifies individual requests for services orequipment. The same authorization number isused throughout the history of the request,whether it is approved, pended, or denied.Assignment - A process in which a doctoror supplier agrees to accept the Medicareprogram's payment as payment in full,except for specific deductible andcoinsurance amounts required of the patient.Bedside nursing services – Servicesincluded under the room and board servicespaid to the facility. These services include,but are not limited to: medicationadministration, IV hydration and IVmedication administration, vaccineadministration, dressing applications,therapies, glucometry testing,catheterizations, tube feedings andirrigations, and equipment monitoringservices. (WAC 182-550-1050)11
Inpatient Hospital ServicesCase mix – A relative value assigned to aDRG or classification of patients in amedical care environment representing theresource intensity demands placed on aninstitution. (WAC 182-550-1050)Behavioral health organization (BHO) –means a single- or multiple-county authorityof other entity operating as a prepaid healthplan with which the Medicaid agency or theagency’s designee cont
Inpatient Hospital Services . Washington Apple Health (Medicaid) Inpatient Hospital Services . Billing Guide . January 1, 2018 . Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.
