California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Section 9792.1 - Payment of Inpatient Services of Health Facilities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Maximum reimbursement for inpatient
					 medical services shall be determined by multiplying 1.20 by the product of the
					 health facility's composite factor and the applicable DRG weight or revised DRG
					 weight if a revised weight has been adopted by the administrative director. The
					 fee determined under this subdivision shall be a global fee, constituting the
					 maximum reimbursement to a health facility for inpatient medical services not
					 exempted under this section. However, preadmission services rendered by a
					 health facility more than 24 hours before admission are separately
					 reimbursable.
(b) Health facilities
					 billing for fees under this section shall present with their bill the name and
					 address of the facility, the facility's Medicare ID number, and the applicable
					 DRG codes.
(c) The following are
					 exempt from the maximum reimbursement formula set forth in subdivision (a):
(1) Inpatient services for the following
					 diagnoses: Psychiatry (DRGs 424-432), Substance Abuse (DRGs 433-437), Organ
					 Transplants (DRGs 103, 302, 480, 481, 495), Rehabilitation (DRG 462 and
					 inpatient rehabilitation services provided in any rehabilitation center that is
					 authorized by the Department of Health Services in accordance with Title 22,
					 §§
												70301,
					 70595 -
					 70603 of the California Code of
					 Regulations to provide rehabilitation services), Tracheostomies (DRGs 482,
					 483), and Burns (DRGs 475 and 504-511).
(2) Inpatient services provided by a Level I
					 or Level II trauma center, as defined in Title 22, California Code of
					 Regulations sections
					 100260,
					 100261, to a patient with an
					 immediately life threatening or urgent injury.
(3) Inpatient services provided by a health
					 facility for which there is no composite factor.
(4) Inpatient services provided by a health
					 facility located outside the State of California.
(5) The cost of durable medical equipment
					 provided for use at home.
(6)
					 Inpatient services provided by a health facility transferring an inpatient to
					 another hospital. Maximum reimbursement for inpatient medical services of a
					 health facility transferring an inpatient to another hospital shall be a per
					 diem rate for each day of the patient's stay in that hospital, not to exceed
					 the amount that would have been paid under Title 8, California Code of
					 Regulations §
												9792.1(a).
					 However, the first day of the stay in the transferring hospital shall be
					 reimbursed at twice the per diem amount. The per diem rate is determined by
					 dividing the maximum reimbursement as determined under Title 8, California Code
					 of Regulations §
												9792.1(a) by the
					 average length of stay for that specific DRG. However, if an admission to a
					 health facility transferring a patient is exempt from the maximum reimbursement
					 formula set forth in subdivision (a) because it satisfies one or more of the
					 requirements of Title 8, California Code of Regulations §
												9792.1(c)(1) through
					 (c)(4), subdivision (c)(6) shall not apply.
					 Inpatient services provided by the hospital receiving the patient shall be
					 reimbursed under the provisions of Title 8, California Code of Regulations
					 §
												9792.1(a).
(7) Implantable hardware and/or
					 instrumentation for DRGs 496 through 500, where the admission occurs on or
					 after April 13, 2001. Implantable hardware and/or instrumentation for DRGs 496
					 through 500, where the admission occurs on or after April 13, 2001, shall be
					 separately reimbursed at the provider's documented paid cost, plus an
					 additional 10% of the provider's documented paid cost not to exceed a maximum
					 of $250.00, plus any sales tax and/or shipping and handling charges actually
					 paid.
(8) Cost Outlier cases.
					 Inpatient services for cost outlier cases where the admission occurs on or
					 after June 29, 2001, shall be reimbursed as follows:
Step 1: Determine the Inpatient Hospital Fee Schedule
						payment amount (DRG relative weight x 1.2 x hospital specific composite
						factor).
Step 2: Determine costs. Costs = (total billed charges x
						total cost-to-charge ratio).
Step 3: Determine outlier threshold. Outlier threshold =
						(Inpatient Hospital Fee Schedule payment amount + hospital specific outlier
						factor).
If costs exceed the outlier threshold, the case is a cost
						outlier case and the admission is reimbursed at the Inpatient Hospital Fee
						Schedule payment amount + (0.8 x (costs - cost outlier threshold)).
NOTE: For purposes of determining whether a case
						qualifies as a cost outlier case under this subsection, implantable hardware
						and/or instrumentation reimbursed under subsection (8) below is excluded from
						the calculation of costs. Once an admission for DRGs 496 through 500 qualifies
						as a cost outlier case, any implantable hardware and/or instrumentation shall
						be separately reimbursed under subsection (8) below.