1 Tex. Admin. Code § 371.203 - TMRP Review Process
(a) The TMRP
review process includes:
(1) Admission review
to evaluate the medical necessity of the admission. For purposes of the TMRP
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 the critical elements
necessary to assign a DRG. The hospital staff is responsible and held
accountable for the accuracy of the required critical elements. Those elements
are age, sex, discharge status, admission date, discharge date, principal
diagnosis, principal and secondary procedures, any complications or
comorbidities (secondary diagnoses), and Present on Admission (POA) indicators.
(A) POA review validates the POA indicator
assigned 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, HHSC revises
the POA indicator for the diagnosis 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 secondary diagnoses and procedures are sequenced correctly. The
principal 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 affect the
patient care in terms of requiring: clinical evaluation, therapeutic treatment,
diagnostic procedures, extended length of hospital stay, increased nursing care
and/or monitoring, or in the case of a newborn, conditions the physician deems
to have clinically significant implications for future health care needs. If
the principal diagnosis, secondary 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 is entered into the
applicable version of the Grouper software for a DRG assignment. CMS-approved
DRG Grouper software considers the required critical elements and determines
the final DRG assignment. If the DRG validation process results in deletions,
changes, or additions to the critical elements and these changes cause the DRG
to be reassigned, HHSC directs the claims administrator to adjust the payment
to the hospital accordingly.
(3) Quality of care review to assess whether
the 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 identified, physician
consultants under contract with HHSC and of the specialty related to the care
provided 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 services that should have been provided in a previous
admission.
(5) Day outlier review,
which includes DRG validation, verifies the medical necessity of each day of
the admission.
(6) Cost outlier
review to verify that services billed were medically necessary, ordered by a
physician or non-physician provider, rendered and billed appropriately, and
substantiated in the medical record.
(b) HHSC reviews the complete medical record
for the requested admission(s) to make decisions on all aspects of this review
process. The complete medical record may include: emergency room records,
medical/surgical history and physical examination, discharge summary,
physicians' progress notes, physicians' orders, lab reports, diagnostic and
imaging reports, operative reports, pathology reports, nurses' notes,
medication sheets, vital signs sheets, therapy notes, specialty consultation
reports, and special diagnostic and treatment records. If the complete medical
record is not available during the review, HHSC issues a preliminary technical
denial and notifies the facility.
(c) A physician consultant under contract
with HHSC makes all decisions concerning medical necessity, cause of
readmission, and appropriateness of setting for the service provided. In the
event the physician consultant determines the services were not medically
necessary, should have been provided in a previous admission, or were not
provided in the appropriate setting, the claim is denied, and HHSC notifies the
hospital in writing. If a hospital claim is denied for lack of medical
necessity or for being provided in an inappropriate setting, HHSC considers for
denial physician and/or non-physician Medicaid provider claims associated with
the hospital admission or service when such claims can be identified and are
deemed to be the result of inappropriate admission orders. Physicians and/or
non-physician providers are notified in writing if the claim for professional
services is denied. The written notification explains the process for appealing
the denial.
(d) The OIG conducts
training for providers, in a manner and format determined by the OIG, on at
least an annual basis to communicate with and educate providers about the DRG
validation criteria used by the OIG in conducting hospital utilization reviews
and audits as outlined in this section.
Notes
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