Section 20-2-I - INPATIENT AND OUTPATIENT CARE RULESA.Definition. For purposes of this schedule, a patient is considered an "inpatient" if formally admitted as an inpatient with the expectation that he or she will require hospital care that is expected to span at least two (2) midnights.B. Health care facilities providing services to workers' compensation claimants must meet requirements of the state of Mississippi.C.Billing and Reimbursement Rules for Inpatient Care.1. Facilities must submit the bill for inpatient services within thirty (30) days after discharge. For those cases involving extended hospitalization, interim bills must be submitted every thirty (30) days.2. Reimbursement for acute inpatient hospital services shall be the lesser of the amount billed or the MAR for the diagnosis-related group (DRG) as fixed by the rules set forth in this section of the Fee Schedule.3. Non-covered charges include but are not necessarily limited to: b. Charges for services not related to the work injury/illness; andc. Services that were not certified by the payer or their representative as medically necessary.4. When reviewing surgical claims, including for outlier consideration, the following apply: a. Most operative procedures require cardiopulmonary monitoring either by the physician performing the procedure or an anesthesiologist/anesthetist. Because these services are integral to the operating room environment, they are considered as part of the OR fee and are not separately reimbursed, nor are they included separately in the total charge for outlier consideration: * Cardiac monitors;
* Oximetry;
* Blood pressure monitor;
* Lasers;
* Microscopes;
* Video equipment;
* Set up fees;
* Additional OR staff;
* Gowns;
* Gloves;
* Drapes;
* Towels;
* Mayo stand covers;
* On-call or call-back fees; and
* After-hours fees.
b. Billing for surgery packs as well as individual items in the packs is not allowed and shall not be included in the total charge for outlier consideration.c. A majority of invasive procedures requires availability of vascular and/or airway access; therefore, the work associated with obtaining this access is included in the cost of the service, i.e., anesthesia-airway access is associated with general anesthesia and is included in the anesthesia charges.d. Recovery room and ICU rates include the charge for cardiac monitoring and oximeter. It is assumed the patient is placed in these special areas for monitoring and specialized care which is bundled into the special care rate. Call-back fees are not reimbursed for recovery room.e. Separate reimbursement is not allowed for setting up portable equipment at the patient's bedside.f. The following items do not qualify for separate reimbursement regardless of inpatient or outpatient status, and are not included in the total charge for outlier consideration: * Applicators, cotton balls, band-aides;
* Syringes;
* Aspirin;
* Thermometers, blood pressure apparatus;
* Water pitchers;
* Alcohol preps; and
* Ice bags.
g. Separate reimbursement is not allowed for equipment such as compressive devices, or other equipment used during the operative or immediate postoperative period.5. Maximum reimbursement is set for the following line item charges. a. IV pump/daily - $50.00b. Venipuncture reimbursement is limited to $4.25 per collection. A collection fee is not appropriate for finger stick, throat culture, or stool specimen collection c. Pharmacy add-mixture/dispensing fee is limited to $4.50 per mixtureD.Implants, Durable Medical Equipment, and Supplies.Generally, durable medical equipment and supplies provided or administered in a hospital setting are not separately reimbursed since they are included in the payment reimbursement.
Unless otherwise specifically provided herein, implantables used in the inpatient setting are included in the applicable MS-DRG reimbursement for inpatient treatment, and, therefore, the provider of inpatient services is not required to furnish the payer with an invoice for implantables.
Implantables used in the outpatient setting, are included in the applicable APC payment for outpatient services, and therefore, the provider of outpatient services is not required to furnish the payer with an invoice for implantables.
E.Reimbursement Methodology. The maximum allowable reimbursement (MAR) for inpatient facility services is provided by MS-DRG in this Fee Schedule. As of the effective date of this publication, reimbursement is the lesser of the total billed charge or the MS-DRG MAR. This methodology includes inpatient psychiatric admissions and Long Term Acute Care (LTAC). Any MS-DRGs outside of this Fee Schedule shall be reimbursed at seventy-five percent (75%) of charges. The lesser of the billed charges or the MS-DRG MAR represent payment in full, unless the outlier payment is applicable, or unless a contract between the payer and provider governs reimbursement, or unless otherwise specifically stated in this Fee Schedule. 1. MS-DRG MAR is calculated by multiplying the Base Rate times the Relative Weight in effect on the date of discharge for the MS-DRG.2. The Base Rate for Mississippi is the current National Medicare Base Rate in effect as of the date of discharge, multiplied by two (2). This is posted annually on the MWCC website, Fee Schedule section.3. Common Medicare add-ons, such as for teaching hospitals (GME), DSH and Capital PPS, will not be allowed, and shall be considered as already included in the enhanced MS-DRG Payment under this Fee Schedule.4. All implantables shall be included in the applicable MS-DRG reimbursement for inpatient treatment, and shall not be reimbursed separately in addition to the MS-DRG payment.5. Outlier Payments. To provide additional reimbursement for cases where the MS-DRG payment is deemed inadequate by the MWCC to cover the costs incurred by the facility, the MWCC has established an outlier payment for high-cost cases. The amount eligible for outlier reimbursement is equal to Total Charges minus MS-DRG Payment minus Implantable Charges minus Non-Covered or Non-Qualified charges (as provided in Part I.B. above) minus the Outlier Threshold. The Outlier Threshold amount shall be specific to each facility and shall be equal to one-half (1/2) of the Medicare MS-DRG outlier threshold . Once the annual inpatient hospital amounts are posted on the MWCC website each year, the Medicare threshold and Mississippi hospital outlier thresholds do not change, regardless of any other updates or corrections subsequently posted by CMS.
6. Any amount determined to be eligible for additional outlier reimbursement shall be reimbursed at fifteen percent (15%) above the facility's cost for the outlier eligible charges. Cost is determined using the facility's cost-to-charge ratio, as determined by Medicare (CMS), which is in effect at the time of discharge. These cost-to-charge ratios are posted annually on the MWCC website, Fee Schedule section. Outlier payment is figured by multiplying the eligible outlier amount by the cost-to-charge ratio, and then adding fifteen percent (15%) to compute the additional outlier payment due.F.Emergency Room Services. Emergency room facility fees, supplies, and treatment are reimbursed according to the Ambulatory Payment Classification system, as set forth herein under the heading "Ambulatory Surgery Center/Outpatient Facility Reimbursement." Laboratory and radiology services are reimbursed at the technical amount listed in the corresponding section of this Fee Schedule. Physician services are to be billed on an appropriate CMS claim form or electronic submission and paid according to the proper section.G.Observation Services1.Definition. Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services may be ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.2.General Guidelinesa. Observation begins when the patient monitoring begins and ends when the order for discharge is written or given verbally by the physician.b. On rare occasions, an observation stay may be extended to forty-eight (48) hours. In such cases, medical necessity must be established and pre-authorization must be given for payment by the payer. c. Services which are NOT considered necessary for observation are as follows: (1) Services that are not reasonable and necessary for the diagnosis and treatment of the work related injury, but are provided for convenience of the patient, family, or physician;(2) Any substitution of an outpatient observation for a medically appropriate inpatient admission;(3) Services ordered as inpatient by the physician but billed as outpatient by the facility;(4) Standing orders for observation following outpatient surgery;(5) Test preparation for a surgical procedure; and(6) Continued care of a patient who has had a significant procedure as identified with OPPS indicator S or T.d. Observation is not reimbursable for routine preparation furnished prior to an outpatient service or recovery after an outpatient service. Please refer to the criteria for observation services.3.Billing and Reimbursementa. Observation status is billed at an hourly monitoring rate. The hourly rate is all inclusive with the exception of non-significant ancillary services. b. Observation is billed at the rate of $300.00 for the first three (3) hours and $80.00 per hour thereafter. Laboratory and radiology are reimbursed according to the Fee Schedule payment limits.c. Revenue code 762 is used to bill observation charges.d. Observation services provided to a patient who is subsequently admitted as an inpatient should be included on the inpatient claim.H.Stand-alone Services. When services are provided as an outpatient service, and are not performed as a surgical procedure, medical procedure, or emergency room service, then reimbursement equals the technical amount listed in the corresponding section of this Fee Schedule.I.Disputed Medical Charges; Abusive or Unfair Billing1. Disputes over charges, fees, services, or other issues related to treatment under the terms of the Workers' Compensation Law shall be resolved in accordance with the Dispute Resolution Rules set forth elsewhere in this Fee Schedule.2. If the MWCC determines that the charge amount for items substantially and consistently exceeds the facility's mark-up ratio, or if a facility's charges for other services or MS-DRGs is substantially and consistently higher than the average charges made for the same services or MS-DRGs by other facilities in the State, then the MWCC may consider this to be an indication of abusive or unfair billing practices, and may order the facility in question to appear and show cause why penalties and other sanctions as allowed by Law should not be imposed on said facility for such abusive billing practices. For purposes of this provision, the mark-up ratio shall be the inverse of the facility's cost-to-charge ratio. The average charges by facilities for service or MS-DRGs may be determined by reference to the publicly available MedPAR file for Medicare inpatient admissions, with due consideration being given to the differences between the Medicare inpatient population and the workers' compensation inpatient population.