471 Neb. Admin. Code, ch. 10, § 002

Current through September 17, 2024

Section 471-10-002 - DEFINITIONS

The following definitions apply:

002.01ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance cost.

002.02ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP. The All-Patient Refined Diagnosis-Related Group software application that assigns patients into categories based on severity of illness and risk of mortality.

002.03BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates.

002.04CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year.

002.05CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average.

002.06COMORBIDITY. The simultaneous presence of two chronic diseases, or conditions, in a patient.

002.07COORDINATION PLAN. An overall program outline for the delivery of a specific service; it is not an individual patient care plan.

002.08COST OUTLIER. Cases which have an extraordinarily high cost as established in 471 Nebraska Administrative Code (NAC) 10-004.03 as eligible for additional payments above and beyond the initial diagnosis-related group payment.

002.09CRITICAL ACCESS HOSPITAL. A hospital licensed as a critical access hospital by the Department of Health and Human Services under 175 NAC 9, and certified for participation by Medicare as a critical access hospital.

002.10DIAGNOSIS-RELATED GROUP (DRG). A group of similar diagnoses combined based on patient age, birth weight, procedure coding, comorbidity, and complications.

002.11DIAGNOSIS-RELATED GROUP (DRG) WEIGHT. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis-related group and severity of illness (SOI).

002.12DIAGNOSTIC SERVICE. An examination or procedure performed either on the patient, or materials obtained from the patient, to provide information for the diagnosis or treatment of a disease or to assess a medical condition. This may include radiological and pathological services.

002.13 DIALYSIS. A process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane.

002.14DIRECT MEDICAL EDUCATION COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education costs associated with approved intern and resident programs. Costs associated with direct medical education are determined from the hospital base year cost reports, and are limited to the maximum per intern and resident amount allowed by Medicare in the base year.

002.15DISPROPORTIONATE SHARE HOSPITAL (DSH). A hospital located in Nebraska is deemed to be a disproportionate share hospital by having either:

(A) A Nebraska Medicaid inpatient utilization rate equal to or above the mean Nebraska Medicaid inpatient utilization rate for hospitals receiving Nebraska Medicaid payments in Nebraska; or

(B) A low-income utilization rate of 25 percent or more.

002.16DISTINCT PART UNIT. A Medicare-certified hospital-based substance abuse, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare.

002.17DURABLE MEDICAL EQUIPMENT. Equipment which withstands repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the client's home.

002.18EMERGENCY MEDICAL CONDITION. A medical or behavioral condition, the onset of which is sudden, manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could result in:

(A) Placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy;

(B) Serious impairment to such person's bodily functions; or

(C) Serious dysfunction of any bodily organ or part; or

(D) With respect to a pregnant woman who is having contractions:

(i) Inadequate time to effect a safe transfer to another hospital before delivery; or

(ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.

002.19HEALTH CARE-ACQUIRED CONDITIONS. A health care-acquired condition means a condition occurring in any inpatient hospital setting, identified as a hospital-acquired condition (HAC) by Medicare other than deep vein thrombosis (DVT) or pulmonary embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients.

002.20HOSPITAL EMERGENCY SERVICES. Services that are necessary to prevent the death of the client or serious impairment of the client's health and, because of the threat to the life or health of the client, necessitate the use of the most accessible hospital equipped to provide the necessary services.

002.21HOSPITAL INPATIENT SERVICES. Services that:

(A) Are ordinarily furnished in a hospital for the care and treatment of inpatients;

(B) Are furnished under the direction of a physician or dentist;

(C) Are furnished in an institution that:

(i) Is maintained primarily for the care and treatment of patients with disorders other than mental diseases;

(ii) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting;

(iii) Meets the requirements for participation in Medicare as a hospital; and

(iv) Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of 42 Code of Federal Regulations (CFR) §482.30, unless a waiver has been granted by the Secretary of the United States Department of Health and Human Services; and

(D) Do not include special needs facilities (SNF) and independent clinical laboratory (ICF) services furnished by a hospital with a swing-bed approval.

002.22HOSPITAL MERGERS. Hospitals that have combined into a single entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Medicaid provider number.

002.23HOSPITAL OUTPATIENT OBSERVATION SERVICES. Observation services are those services furnished by a hospital on the hospital premises, including use of a bed and periodic monitoring by a hospital's nursing staff or other staff, which are reasonable and necessary to determine the need for a possible admission to the hospital as an inpatient. Some patients may require a second day of outpatient observation services. A maximum of 48 hours of observation may be reimbursed. When a client receives hospital observation services and is thereafter admitted as an inpatient of the same hospital, the hospital observation services are included in the hospital's payment for the inpatient services.

002.24HOSPITAL OUTPATIENT SERVICES. Preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients under the direction of a physician, optometrist, ophthalmologist, audiologist or dentist in an institution that meets provider requirements.

002.25HOSPITAL-AFFILIATED AMBULATORY SURGICAL CENTER (HAASC). An ambulatory surgical center operated by a hospital. A hospital-affiliated ambulatory surgical center (HAASC) may be covered under Medicare, and therefore under Nebraska Medicaid, as an ambulatory surgical center (ASC) or a hospital-affiliated ambulatory surgical center (HAASC).

002.26HOSPITAL-ACQUIRED CONDITION (HAC). A condition that is reasonably preventable and was not present or identifiable at hospital admission but is either present at discharge or documented after admission.

002.27HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital-specific operating allowable cost associated with treating Nebraska Medicaid patients. Operating costs include the major moveable equipment portion of capital-related costs, but exclude the building and fixtures portion of capital-related costs, direct medical education costs, and indirect medical education costs.

002.28HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO. Hospital-specific cost-to-charge ratio is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios used for outlier cost payments and transplant diagnosis-related group cost-to-charge ratio (CCR) payments are derived from the outlier cost-to-charge ratios (CCR) in the Medicare inpatient prospective payment system.

002.29INDEPENDENT CLINICAL LABORATORY (ICF). A laboratory which is operated by or under the supervision of a hospital or the organized medical staff of the hospital which does not meet the definition of a hospital is considered to be an independent laboratory. However, a laboratory serving hospital inpatients and outpatients and operated on the premises of a hospital which meets the definition of a hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not classified as an independent clinical laboratory. The hospital's certification covers the services performed in this laboratory.

002.30INDIRECT MEDICAL EDUCATION COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education cost payments.

002.31INFANT OR INFANCY. The time period from an individual's birth through completion of one year of age.

002.32INPATIENT. A patient who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who:

(A) Receives room, board and professional services in the institution for a 24 hour period or longer; or

(B) Is expected by the institution to receive room, board and professional services in the institution for a 24 hour period or longer even though it later develops that the patient dies, is discharged or is transferred to another facility and does not actually stay in the institution for 24 hours.

002.33INPATIENT DAYS. The number of days of care covered for inpatient hospital services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Nebraska Medicaid reporting purposes, even if the hospital uses a different definition of a day for statistical or other purposes. The day of admission is counted as a full day.

002.33(A)PART OF DAY. Except for the day of admission, a part of a day, including the day of discharge, death, or a day on which a patient begins a leave of absence, is not counted as a day. Charges for ancillary services on the day of discharge or death, or the day on which a patient begins a leave of absence are covered. If inpatient admission and discharge or death occur on the same day, the day is considered a day of admission and counted as one inpatient day.

002.33(B)ANCILLARY AREAS. When a registered inpatient is occupying any other ancillary area, such as surgery or radiology, at the census-taking hour before occupying an inpatient bed, the patient must be included in the inpatient census of the routine care area, not the ancillary area.

002.33(C)MEDICARE METHODOLOGY. The Department utilizes the current Medicare methodology in accounting for the inpatient accommodations on the Nebraska Medicare cost report.

002.34LOW-INCOME UTILIZATION RATE. For the cost reporting period ending in the calendar year preceding the Nebraska Medicaid rate period, the sum, expressed as a percentage, of the fractions, calculated from acceptable data submitted by the hospital as follows:

(A) Total Nebraska Medicaid inpatient revenues, excluding those payments for disproportionate share hospitals, paid to the hospital, plus the amount of cash subsidies received directly from state and local governments in a cost reporting period, divided by the total amount of revenues of the hospital for inpatient services, including the amount of cash subsidies received directly from state and local governments and excluding payments for disproportionate share hospitals in the same cost reporting period; and

(B) The total amount of the hospital's charges for hospital inpatient services attributable to uncompensated care in ending in the calendar year preceding the Nebraska Medicaid rate period, less the amount of any cash subsidies identified in item (A) of this definition in the cost reporting period reasonably attributable to hospital inpatient services, divided by the total amount of the hospital's charges for inpatient services in the hospital for the same period. The total inpatient charges attributed to uncompensated care does not include contractual allowances and discounts, other than for uncompensated care for patients not eligible for Nebraska Medicaid, that is, reductions in charges given to other third-party payors.

002.35MEDICAID ALLOWABLE INPATIENT CHARGES. Total claim submitted charges less claim non-allowable amount.

002.36MEDICAID ALLOWABLE INPATIENT DAYS. The total number of covered Medicaid inpatient days.

002.37MEDICAID INPATIENT UTILIZATION RATE. The ratio of one allowable Medicaid inpatient days, as determined by Nebraska Medicaid, two total inpatient days, as reported by the hospital on its Medicare cost report ending in the calendar year preceding the Medicaid rate period. Inpatient days for out-of-state Nebraska Medicaid patients for the same time period will be included in the computation of the ratio if reported to the Department prior to the beginning of the Nebraska Medicaid rate period.

002.38MEDICAID RATE PERIOD. The period of July 1 through the following June 30.

002.39MEDICAL NECESSITY. Health care services and supplies which are medically appropriate and:

(A) Necessary to meet the basic health needs of the client;

(B) Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;

(C) Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;

(D) Consistent with the diagnosis of the condition;

(E) Required for means other than convenience of the client or his or her physician;

(F) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;

(G) Of demonstrated value; and

(H) No more intense level of service than can be safely provided.

002.40MEDICAL REVIEW. Review of Nebraska Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay, completeness, adequacy, and quality of care; appropriateness of admission, discharge and transfer; and appropriateness of prospective payment outlier cases.

002.41MEDICAL SOCIAL SERVICES. Medical social services are those social services which contribute meaningfully to the treatment of a patient's condition. These services include, but are not limited to:

(A) Assessment of the social and emotional factors related to the patient's illness, need for care, response to treatment, and adjustment to care in the hospital;

(B) Appropriate action to obtain case work services to assist in resolving problems in these areas; and

(C) Assessment of the patient's medical and nursing requirements, his or her home situation, his or her financial resources, and the community resources available to him or her in making the decision regarding their discharge.

002.42MEDICAL SUPPLIES. Expendable or specified reusable supplies required for care of a medical condition and used in the client's home must be prescribed by a physician or other licensed practitioner within the scope of their licensure. This includes dressings, colostomy supplies, catheters, and other similar items.

002.43MEDICARE COST REPORT. The report filed by each facility with its Medicare intermediary. The Medicare cost report is available through the National Technical Information Service.

002.44NEONATAL INTENSIVE CARE. Intensive care services provided to an infant in an intensive care unit specially equipped to care for infants.

002.45NEW OPERATIONAL FACILITY. A facility providing inpatient hospital care which meets one of the following criteria:

(A) A licensed newly constructed facility, which either totally replaces an existing facility or which is built at a site where hospital inpatient services have not previously been provided;

(B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or

(C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months.

002.46NON-PATIENT. An individual receiving services who is neither an inpatient nor an outpatient. When a sample or specimen is obtained by personnel not employed by the hospital and is sent to the hospital for tests, the tests are non-patient services because the patient is not registered as an inpatient or an outpatient of the hospital. If the sample is obtained by hospital personnel, the tests are outpatient services.

002.47NURSERY CARE. Services for a newborn child from time of birth to time of discharge of the mother from the facility.

002.48OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education costs, and indirect medical education costs.

002.49 OTHER PROVIDER-PREVENTABLE CONDITIONS (OPPC). A wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

002.50ORTHOTICS. Rigid or semi-rigid devices to prevent or correct physical deformity or malfunction, to support a weak or deformed part of the body, or to eliminate motion in a diseased or injured part of the body.

002.51OUTPATIENT. A person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services.

002.52PASS OR LEAVE OF ABSENCE. A patient is absent from the hospital, but has not been discharged from the facility. A hospital may place a patient on a leave of absence when readmission is expected, and the patient does not require a hospital level of care during the interim period.

002.53PATHOLOGICAL SERVICES. Microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or other pathological examinations or procedures performed on materials obtained from the patient to provide information for the diagnosis or treatment of a disease or an assessment of the medical condition of the patient.

002.54PRESENT ON ADMISSION (POA) INDICATOR. A status code the hospital uses on an inpatient claim that indicates if a condition was present or incubating at the time the order for inpatient admission occurs.

002.55PROSTHETIC. A device which replaces a missing part of the body.

002.56PROVIDER-PREVENTABLE CONDITIONS (PPC). An umbrella term which is defined as two distinct categories: health care-acquired conditions (HCAC) and other provider-preventable conditions (OPPC).

002.57RADIOLOGICAL SERVICES. Services in which x-rays or rays from radioactive substances are used for diagnostic or therapeutic purposes and associated medical services necessary for the diagnosis and treatment of the patient.

002.58 REPORTING PERIOD. Same reporting period as that used for its Medicare cost report.

002.59RESOURCE INTENSITY. The relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease.

002.60RISK OF MORTALITY (ROM). The likelihood of dying.

002.61SEVERE OBESITY. Body Mass Index greater than 35.

002.62SEVERITY OF ILLNESS LEVEL (SOI). The extent of physiologic decompensation or organ system loss of function.

002.63CLINICAL TRIALS. For services not subject to Food and Drug Administration (FDA) approval, the following definitions apply:

(A)Phase I: Initial introduction of an investigational service into humans.

(B)Phase II: Controlled clinical studies conducted to evaluate the effectiveness of the service for a particular indication or medical condition of the patient; these studies are also designed to determine the short-term side effects and risks associated with the new service.

(C)Phase III: Clinical studies to further evaluate the effectiveness and safety of a service that is needed to evaluate the overall risk/benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the new service to the current recommended standard of care.

002.64TAX-RELATED COSTS. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to the Medicaid Voluntary Contribution Provider Specific Tax Amendment of 1991 (P.L. 102-234) or any amendments thereto, franchise fee, license fee, or hospital specific tax, fee or assessment imposed by the local, state or federal government, but not including income taxes.

002.65THERAPEUTIC SERVICES. Services and supplies which are not diagnostic services, are furnished incident to the services of physicians and practitioners, and which aid physicians and practitioners in the treatment of patients.

002.66UNCOMPENSATED CARE. Uncompensated care includes the difference between costs incurred and payments received in providing services to Nebraska Medicaid patients and uninsured.

002.67WARD. Either:

(A) A large room in the hospital for the accommodation of several patients; or

(B) A division within a hospital for the care of numerous patients having the same condition.

471 Neb. Admin. Code, ch. 10, § 002

Amended effective 11/9/2020

Amended effective 6/6/2022