10A NCAC 22G .0206. SPECIAL SITUATION

(a)  In order to be eligible for inpatient hospital reimbursement under Section .0200 of this Subchapter, a patient must be admitted as an inpatient and stay past midnight in an inpatient bed.  The only exceptions to this requirement are those admitted inpatients who die or are transferred to another acute care hospital on the day of admission.  Hospital admissions prior to 72 hours after a previous inpatient hospital discharge are subject to review by the Division of Medical Assistance, in order to assure proper billing.  Services for patients admitted and discharged on the same day and who are discharged to home or to a non‑acute care facility must be billed as outpatient services.  In addition patients who are admitted to observations status do not qualify as inpatients, even when they stay past midnight.  Patients in observation status for more than 30 hours must either be discharged or converted to inpatient status.

(b)  Outpatient services provided by a hospital to patients within the 24 hour period prior to an inpatient admission in the same hospital that are related to the inpatient admission shall be bundled with the inpatient billing.

(c)  When a patient is transferred between hospitals, the discharging hospital shall receive a pro‑rated payment equal to the normal DRG payment multiplied by the patient's actual length of stay divided by the geometric mean length of stay for the DRG.  When the patient's actual length of stay equals or exceeds the geometric mean length of stay for the DRG, the transferring hospital receives full DRG payment.  Transfers are eligible for cost outlier payments.  The final discharging hospital shall receive the full DRG payment.

(d)  For discharges occurring on or after October 1, 2001, a discharge of a hospital inpatient is considered to be a transfer under Paragraph (c) of this Rule when the patient's discharge is assigned to one of the following qualifying diagnosis-related groups, DRGs 14, 113, 209, 210, 211, 236, 263, 264, 429, and 483 and the discharge is made under any of the following circumstances:

(1)           To a hospital or distinct part hospital unit excluded from the DRG reimbursement system;

(2)           To a skilled nursing facility; or

(3)           To home under a written plan of care for the provision of home health services from a home health agency and those services begin within three days after the date of discharge.

(e)  Days for authorized skilled nursing for intermediate care level for service rendered in an acute care hospital shall be reimbursed at a rate equal to the average rate for all such Medicaid days based on the rates in effect for the long term care plan year beginning each October 1.  Days for lower than acute level of care for ventilator dependent patients in swing‑bed hospitals or that have been down‑graded through the utilization review process shall be paid for up to 180 days at a lower level ventilator‑dependent rate if the hospital is unable to place the patient in a lower level facility.  An extension shall be granted if in the opinion of the Division of Medical Assistance the condition of the patient prevents acceptance of the patient.  A single all inclusive prospective per diem rate shall be paid, equal to the average rate paid to nursing facilities for ventilator‑dependent services.  The hospital must actively seek placement of the patient in an appropriate facility.

(f)  The Division of Medical Assistance shall make a retrospective review of any transfers to a lower level of care prior to the expiration of the average length of stay for the applicable DRG.  The Division of Medical Assistance shall adjust the DRG payment if the transfer is deemed to be inappropriate, based on the preponderance of evidence of a case by case review.

(g)  In state‑operated hospitals, the appropriate lower level of care rates equal to the average rate paid to state operated nursing facilities, shall be paid for skilled care and intermediate care patients awaiting placement in a nursing facility bed.

(h)  For an inpatient hospital stay where the patient is Medicaid eligible for only part of the stay, the Medicaid program shall pay the DRG payment less the patient's liability or deductible, if any, as provided by 10A NCAC 21B .0406 and .0407.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447 Subpart C;

Eff. February 1, 1995;

Temporary Amendment Eff. December 10, 2001;

Temporary Amendment Expired September 29, 2002;

Amended Eff. August 1, 2004.