N.J. Admin. Code § 10:52-5.8

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:52-5.8 - Patient care cost findings: direct costs per case, physician and nonphysician

(a) Hospital case-mix shall be determined as follows:

1. Uniform Bill-Patient Summary (UB-PS) data shall be used for determination of hospital case-mix. The appropriate patient records for the reporting period corresponding with the Financial Elements Report shall be classified into Diagnosis Related Groups (DRGs) using the following items:

i. Principal diagnosis;

ii. Secondary diagnosis;

iii. Principal and other procedures;

iv. Age;

v. Sex;

vi. Discharge status; and

vii. Birthweight (newborn).

2. Outliers, which are defined as patients displaying atypical characteristics relative to other patients, for example, inordinately long or short lengths of stay, shall be determined by DRG using established trim points; any case beyond a trim point is considered an outlier. Hospitals must make every attempt to correct unacceptable data and hospitals for which more than 10 percent of the UB-PS data are missing or unacceptable must resubmit data or correct the unusable data before case-mix estimation will be attempted.

3. Outpatient case-mix shall consist of emergency service, clinic, home health agency, renal dialysis, home dialysis, ambulatory surgery, same day psychiatry, and private referred patients, as reported to the Division.

4. Same Day Surgical Services shall be considered a clinical, outpatient service but are assigned to a DRG and reported on a UB-PS (a bill type 13X).

(b) Measures of resource use are listed as follows:

1. For each patient with a Uniform Bill (UB), measures of resource use shall be calculated to distribute costs among the UB. Measures of resource use represent services provided to patients associated with each cost center. Patient days are associated with routine service cost, emergency room admissions with emergency service cost, and ancillary and therapeutic charges with ancillary and therapeutic service cost. The measures of resource use is a ratio of admissions reported on the hospital's cost report over the hospital's UB billing data. Costs are derived from the Actual Reporting Forms and are associated with admissions. Therefore, an adjustment is made to align the measures of resource use to the inpatient cost. The adjustment is the ratio of total admissions to total UB records. This results in a total adjusted measure of resource use. The hospitals shall make reasonable efforts to correct data unacceptable to the Division or Department of Health.

Center	Measure of	Calculation of
Resource Use	Inpatients
ROUTINE SERVICES
MSA &	Medical-Surgical	Patient Days	Total LOS less ICU,
Acute Care Units	CCU, NBN and OBS LOS
ACU
PED &	Pediatrics
PSA &	Psychiatric Acute
Care Units
PSY &	Psychiatric/Psychological
Services
OBS	Obstetrics
BCU	Burn Care Unit	BCU LOS
ICU&	Intensive Care Unit	Patient Days	ICU + CCU LOS
CCU	Coronary Care Unit
NNI	Neonatal Intensive	NNI Patient Days	Total ICU LOS for
Care Unit	Newborn DRGs
NBN	Newborn Nursery	NBN Patient Days	Total LOS for Newborn
DRGs less ICU LOS
AMBULATORY SERVICES
EMR	Emergency Service	EMR Charges	EMR Admissions
(Inpatient EMR
Revenue and EMR
Admissions)
CLN	Clinics	CLN Charges	None
HHA	Home Health Agency	OHS Charges	None
ANCILLARY SERVICES
ANS	Anesthesiology	ANS Charges	Direct
CCA	Cardiac Catheterization	CCA Charges	Direct
DEL	Delivery and Labor	DEL Charges	Direct
Room
DIA	Dialysis	DIA Charges	Direct
DRU	Drugs Sold to Patients	PHM Charges (DRU)	Direct
EKG	Electrocardiology and	EDG Charges	Direct
Diagnostic
NEU	Neurology
LAB	Laboratory	BBK Charges and LAB	Direct
Charges
MSS	Medical-Surgical	CSS Charges (MSS)	Direct
Supplies Sold to
Patients
NMD	Nuclear Medicine	NMD Charges	Direct
OCC	Occupational and	OPM Charges	Direct
Recreational Therapy
SPA	Speech Pathology and	Direct
Audiology
ORG	Organ Acquisition and	ORR Charges	Direct
ORR	Operating and
Recovery Rooms
PHT	Physical Therapy	PHT Charges	Direct
RAD	Diagnostic Radiology	RAD Charges	Direct
RSP	Respiratory Therapy	RSP Charges	Direct
THR	Therapeutic Radiology	THR Charges	Direct

(c) Cost per case allocation:

1. The Direct Patient Care Costs of each center (after the allocation of patient care general services in N.J.A.C. 10:52-5.11 and 5.12) are separated between inpatient, outpatient, and Skilled Nursing Facility (SNF) costs. Outpatient and SNF costs are excluded from the inpatient rates based on gross revenue reported to the Division. The total inpatient costs from each cost center are then divided by the hospital's corresponding total adjusted measure of resource use. This calculation produces ratios, including cost per patient day, cost per EMR admission, or a cost ratio per ancillary or therapeutic charge for each cost center. Each ratio is then multiplied by the corresponding cost center's measure of resource use of each DRG to calculate a cost per case for the hospital's case mix.

i. Patient days will be employed as the Measures of Resource Use to allocate MSA, PED, PSA, and OBS nursing costs. While patient days are used, the MSA, PED, PSA, OBS centers will be combined into ACU and ICU, and CCU will be combined into ICU. All other routine centers will remain as above.

N.J. Admin. Code § 10:52-5.8

Amended by 50 N.J.R. 1261(a), effective 5/21/2018