Inpatient Hospital Services

1 INDIANA HEALTH COVERAGE PROGRAMS PR O V I D E R RE F E R E N C E MO D U L E Inpatient Hospital Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 3 5 P U B L I S H E D : A P R I L 1 2 , 2 0 2 2 P O L I C I E S A N D P R O C E D U R E S A S O F A P R I L 1 , 2 0 2 1 V E R S I O N : 5 . 0 Copyright 2022 Gainwell Technologies. All rights reserved. Library Reference Number: PROMOD00035 iii Published: April 12, 2022 Policies and procedures as of April 1, 2021 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of Oct.

2 1, 2015 Published: Feb. 25, 2016 New document FSSA and HPE Policies and procedures as of April 1, 2016 Published: Sept. 20, 2016 Scheduled update FSSA and HPE Policies and procedures as of April 1, 2016 (CoreMMIS updates as of Feb. 13, 2017) Published: May 16, 2017 CoreMMIS update FSSA and HPE Policies and procedures as of Sept. 1, 2017 Published: Nov. 30, 2017 Scheduled update FSSA and DXC Policies and procedures as of Jan. 1, 2019 Published: Oct. 1, 2019 Scheduled update FSSA and DXC Policies and procedures as of March 1, 2020 Published: June 11, 2020 Scheduled update FSSA and DXC Policies and procedures as of April 1, 2021 Published: April 12, 2022 Scheduled update.

3 Edited text as needed for clarity Replaced DXC references with Gainwell Updated the General Inpatient Billing and Coding Procedures section and added Diagnosis Codes subsection Added the Occurrence Codes section Updated the Grouper section Updated the Length of Stay section In the DRG Outlier, Capital Costs and Medical Education Costs Payment section, updated the threshold amount for outlier payments Removed the Hoosier Healthwise Package C Exceptions to DRG and LOC Reimbursement Systems section Updated the Base Rate for Children s Hospitals section In the Hospital -Acquired Conditions Policy section, updated the age range for pediatric patients FSSA and Gainwell Inpatient Hospital Services iv Library Reference Number: PROMOD00035 Published: April 12, 2022 Policies and procedures as of April 1, 2021 Version.

4 Version Date Reason for Revisions Completed By Updated the note in the Inpatient Blood Factor Claims section Corrected information in the Outpatient Service Within Three Days of an Inpatient Stay section Library Reference Number: PROMOD00035 v Published: April 12, 2022 Policies and procedures as of April 1, 2021 Version: Table of Contents Introduction .. 1 Prior Authorization for Hospital Inpatient Admissions .. 1 PA Policy for Inpatient Stays for Burn Care .. 2 PA Policy for Inpatient Stays for Dually Eligible Members .. 2 Inpatient Admission Criteria .. 3 Acute Care Hospital Admission and Continued Stay Criteria for Adults.

5 3 Acute Care Hospital Admission and Continued Stay Criteria for Pediatrics .. 5 Inpatient Rehabilitation Admission and Discharge 8 Dental Admissions .. 9 Inpatient Burn Admissions .. 10 General Inpatient Billing and Coding Procedures .. 12 Revenue Code Itemization .. 12 Diagnosis Codes .. 12 Present-on-Admission Indicators .. 13 Occurrence Codes .. 14 Reimbursement Methodology for Inpatient Services .. 14 Diagnosis-Related Group Reimbursement System .. 15 Inpatient Level-of-Care Reimbursement System .. 17 Reimbursement for Capital Costs .. 19 Reimbursement for Medical Educational Costs.

6 19 Outlier Payments .. 20 Base Rate for Children s Hospitals .. 20 Change in Coverage During Inpatient Stay .. 21 Inpatient Coverage for Presumptively Eligible Members .. 21 Inpatient Coverage for Inmates .. 21 Hospital -Acquired Conditions Policy .. 21 Reimbursement for Promoting Interoperability Program .. 23 Long-Term Acute Care Hospital Services .. 23 Admission Criteria .. 23 Continued Stay 26 Discharge Criteria .. 26 LTAC Billing .. 26 LTAC Reimbursement .. 27 Inpatient Blood Factor Claims .. 27 Medicare Exhaust Claims and Inpatient Services .. 28 Benefits Exhausted Prior to Inpatient Admission.

7 28 Benefits Exhausted During an Inpatient Stay .. 28 Observation Billing .. 28 Transfers .. 29 Readmissions .. 30 Inpatient Stays Less Than 24 Hours .. 30 Expiration Within One Day of Birth .. 30 Inpatient -Only Codes .. 30 Outpatient Service Within Three Days of an Inpatient Stay .. 31 Coding Claims for 32 Unit and Age Limitations on Inpatient Neonatal and Pediatric Critical Care Services .. 32 Newborn Screening .. 32 Newborn Heelstick Screening Dried Blood Spot Sample .. 33 Newborn Screening for Critical Congenital Heart Disease Pulse Oximetry .. 33 Newborn Hearing Screening Early Hearing Detection and Intervention.

8 33 Library Reference Number: PROMOD00035 1 Published: April 12, 2022 Policies and procedures as of April 1, 2021 Version: Inpatient Hospital Services Note: The information in this module applies to Indiana Health Coverage Programs (IHCP) Services provided under the fee-for-service (FFS) delivery system. For information about Services provided through the managed care delivery system including Healthy Indiana Plan (HIP), Hoosier Care Connect or Hoosier Healthwise member Services providers must contact the member s managed care entity (MCE) or refer to the MCE provider manual.

9 MCE contact information is included in the IHCP Quick Reference Guide, available at For updates to information in this module, see IHCP Banner Pages and Bulletins at Introduction Subject to the limitations described in this module, the Indiana Health Coverage Programs (IHCP) covers Inpatient Services (such as acute care, mental health and rehabilitation care) when the Services are both of the following: Provided or prescribed and documented by a physician Medically necessary for the diagnosis or treatment of the member s condition Note: This module includes information about IHCP coverage, billing and reimbursement for Inpatient Services .

10 For additional information specific to Inpatient mental health and addiction Services , see the Behavioral Health Services module. Prior Authorization for Hospital Inpatient Admissions In accordance with Indiana Administrative Code 405 IAC 5-17-2, the IHCP requires prior authorization (PA) for all nonemergency Inpatient Hospital admissions, with the following exceptions: Routine vaginal and C-section deliveries Inpatient Hospital admissions covered by Medicare In all other cases, nonemergency Inpatient Hospital admissions including all elective or planned admissions and admissions for which the patient s condition permitted adequate time to schedule suitable accommodation require PA.