N.J. Admin. Code § 10:52-14.16
Current through Register Vol. 56, No. 8, April 15, 2024
Section 10:52-14.16 - Payment for readmissions(a) For New Jersey hospitals, if a patient is readmitted to the same hospital for the same or similar diagnosis within seven days, the second claim submitted for payment will be denied. For dates of service before October 1, 2015, the same or similar principal diagnosis is defined as principal diagnoses with the same first three digits in accordance with the International Classification of Diseases, 9th Edition, Clinical Modification published by Practice Management Information Corporation. For dates of service on or after October 1, 2015, the same or similar principal diagnosis is defined as principal diagnoses in the same clinical diagnosis group, determined by the range in which the first three characters of the diagnosis code fall (for example, A00 - B99 is a clinical diagnosis group entitled "Certain infectious and parasitic diseases") in accordance with the International Classification of Diseases, 10th Revision, with Clinical Modifications (ICD-10-CM). For these readmissions, requests for payment of services related to the two hospital inpatient stays shall be combined on the same claim form for reimbursement purposes. 1. In the event that one claim has a date of service prior to October 1, 2015, and another claim has a date of service on or after October 1, 2015, the principal diagnosis reported on the first claim as an International Classification of Diseases, 9th Revision, with Clinical Modifications (ICD-9-CM) diagnosis code, is compared to the principal diagnosis reported on the other claim as an International Classification of Diseases, 10th Revision, with Clinical Modifications (ICD-10-CM) diagnosis code, using the Centers for Medicare and Medicaid Services (CMS) General Equivalency Mapping (GEM) criteria, 2014 Version, which is incorporated herein by reference, as amended and supplemented. Information regarding the CMS GEM can be found at http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.(b) The denial and subsequent combination of claims specified in (a) above may be appealed by following the process specified in (b)1 through 3 below. 1. For a hospital with non-delegated utilization review, the hospital shall request an appeal through its QIO. Hospitals that are delegated for utilization review shall request an appeal through the hospital's appeal process and obtain a final appeal decision from its Physician Advisor (PA).2. An appeal that is approved by the QIO or PA shall be submitted to the Division's fiscal agent, along with a letter from the hospital's QIO or PA, on the QIO's or hospital's letterhead, with a determination that the two hospital stays should not be combined, including the reason supporting its determination, along with an original signature of the hospital's Physician Advisor or QIO Physician Advisor. i. The letter from the QIO or PA shall also include the beneficiary's name, Medicaid identification number, dates of service for the paid and denied claims and the hospital's Medicaid provider number.ii. The discharge summary shall be provided for both the paid and denied claims. For stays less than 48 hours, progress notes may be used in lieu of discharge summaries.3. The Division's fiscal agent will forward appeals that meet the requirements in (b)1 and 2 above to the Division's Office of the Medical Director. Each admission will be evaluated by New Jersey licensed physicians on a case-by-case basis to determine whether the admission and readmission to the same hospital should be combined.(c) The requirements in (a) and (b) above apply to New York hospitals for readmissions within 30 days and apply to Pennsylvania hospitals for readmissions within 31 days. New York and Pennsylvania appeal requests shall be mailed to: Division of Medical Assistance and Health Services
Attention: Hospital Discharge/Readmit Appeals
Mail Code #44
P.O. Box 712
Building 7, Room 302
Trenton, NJ 08625-0712
N.J. Admin. Code § 10:52-14.16
Amended by 48 N.J.R. 962(b), effective 6/6/2016