Texas Register, Volume 38, Number 40, Pages 6747-6996, October 4, 2013 Page: 6,757
6747-6996 p. ; 28 cm.View a full description of this periodical.
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of HHSC with broad rulemaking authority; Human Resources
Code 32.021 and Texas Government Code 531.021(a),
which provides HHSC with the authority to administer the Texas
Medicaid program; and Texas Government Code 531.102(a),
which permits HHSC-OIG to obtain any information or technol-
ogy necessary to enable the office to meet its responsibilities.
The proposed amendments affect Human Resources Code
Chapter 32 and the Government Code Chapter 531. The
proposed amendments do not affect any other statute, article,
or code.
371.200. Inpatient Hospital Utilization Review Program.
(a) The Texas Medical Review Program (TMRP) is the inpa-
tient hospital utilization review process used by the Texas Health and
Human Services Commission (Commission) for hospitals reimbursed
under the Commission's prospective payment system. The Commis-
sion conducts the TMRP in accordance with:
(1) applicable federal regulations at 42 Code of Federal
Regulations Part 456, Subparts A, B, and C, which require the Com-
mission to operate a utilization review program that controls the uti-
lization of inpatient hospital services and assesses the appropriateness
and quality of those services; and
(2) an approved waiver under the Social Security Act,
1903(i)(4), as it relates to the use of Title XVIII utilization review
procedures for Title XIX patients in acute care general hospitals other
than hospitals reimbursed under the Tax Equity and Fiscal Responsi-
bility Act (TEFRA) reimbursement principles.
(b) The TEFRA review process relates directly to hospitals re-
imbursed under the TEFRA reimbursement principles and facility spe-
cific per diem methodology [(children's hospitals) or through the Lon-
eSTAR Select H contracting program (freestanding psychiatric hospi-
tals)].
371.201. Case Selection Process.
(a) The Texas Health and Human Services Commission (Com-
mission) selects Texas Medical Review Program (TMRP) cases for re-
view by a statistically valid random sampling methodology and/or fo-
cused case selection. Cases will consist of paid inpatient claims for
diagnostic related groups (DRGs), which may include:
(1) Readmissions up to 30 [thirty] days;[,]
(2) Ambulatory surgical procedures billed on inpatient
claims;[,]
(3) Questionable admissions or claims coding identified by
other entities; []
(4) Admissions identified through the Commission's qual-
ity review program as potential quality of care concerns; [,]
(5) DRG payments made to freestanding rehabilitation fa-
cilities;[, and]
(6) Day or cost outlier payments; or[;]
(7) Any other DRG or claims submission errors.
(b) The Commission selects Tax Equity and Fiscal Responsi-
bility Act and facility specific per diem methodology [-TEFRA) and
LoneSTAR Seleet 1 eentracing program] cases for review by a sta-
tistically valid random sampling methodology and/or focused case se-
lection. Cases will consist of paid inpatient claims for admissions to
children's hospitals and freestanding psychiatric facilities.
371.203. Texas Medical Review Program (TMIRP) Review Process.
(a) The TMRP review process includes, but is not limited to:(1) Admission review to evaluate the medical necessity of
the admission. For purposes of the TMRP[, Tax Equity and Fiseal Re-
sponsibility Act (FRA) and oneST AR Selet Contract] reviews,
medical necessity means the patient has a condition requiring treatment
that can be safely provided only in the inpatient setting.
(2) Diagnosis related group (DRG) validation to confirm
documentation in the medical record of [that] the critical elements nec-
essary to assign a DRG. The hospital [are present in the medical record.
Hospital] staff is [are] responsible and held accountable for the accu-
racy of the required critical elements. Those elements are age, sex,
discharge status, admission date, discharge date, principal diagnosis,
principal and secondary procedures, [and] any complications or co-
morbidities (secondary diagnoses), and Present on Admission (POA)
indicators. [Tifs process also determines]
(A) POA review will validate the POA indicator as-
signed to the principal and secondary diagnoses codes reported on
claim forms. If it is determined that the principal and/or secondary
diagnoses were not present at the time the order for inpatient admission
occurs, the Commission will revise the POA indicator for the diag-
nosis code. Conditions that develop during an outpatient encounter,
including emergency department, observation, or outpatient surgery
are considered POA.
(B) DRG validation confirms that the principal and sec-
ondary diagnoses and procedures are sequenced correctly. The prin-
cipal diagnosis is the diagnosis (condition) established after study to
be chiefly responsible for occasioning the admission of the patient to
the hospital for care. The secondary diagnoses are conditions that af-
fect the patient care in terms of requiring: clinical evaluation, ther-
apeutic treatment, diagnostic procedures, extended length of hospital
stay, increased nursing care and/or monitoring, or in the case of a new-
born, conditions the physician deems to have clinically significant im-
plications for future health care needs. If the principal diagnosis, sec-
ondary diagnoses, or procedures are not substantiated in the medical
record, are not sequenced correctly, or have been omitted, codes may
be deleted, changed, or added.
(C) When the correct diagnosis and procedure coding
and sequencing have been determined, the information will be entered
into the applicable version of the Grouper software for a DRG assign-
ment. The Centers for [For] Medicare and Medicaid Services (CMS)
approved DRG Grouper software considers the required critical ele-
ments and determines the final DRG assignment. If the DRG valida-
tion process results in deletions, changes, or additions to the critical
elements and these changes cause the DRG to be reassigned, the Texas
Health and Human Services Commission (Commission) will direct the
claims administrator to adjust the payment to the hospital accordingly.
(3) Quality of care review to assess whether the [quality
of] care provided meets generally accepted standards of medical and
hospital care practices or puts the patient at risk of unnecessary injury,
disease, or death. Quality of care review includes the use of discharge
screens and generic quality screens. If quality of care issues are iden-
tified, physician consultants under contract with the Commission, and
of the specialty related to the care provided, will determine possible
clinical recommendations or corrective actions.
(4) Readmission review to evaluate each admission on its
individual merits and determine if the second or subsequent admissions
resulted from a premature discharge or were required to provide ser-
vices that should have been provided in a previous admission.
(5) Day outlier review, which includes DRG validation,
verifies [to verify] the medical necessity of each day of the admission
[and includes DRG validation].PROPOSED RULES October 4, 2013 38 TexReg 6757
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Texas. Secretary of State. Texas Register, Volume 38, Number 40, Pages 6747-6996, October 4, 2013, periodical, October 4, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth342082/m1/11/: accessed April 24, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.