Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-036 - Episodes 1-12 and State Plan Amendment #2012-014

Current through Register Vol. 49, No. 6, June, 2024
SECTION II - EPISODES OF CARE
213.000 CONGESTIVE HEART FAILURE (CHF)
			 EPISODES
213.100 Episode
			 Definition/Scope of Services
A.
Episode subtypes:
There are no
			 subtypes for this episode type.
B.
Episode trigger:
Inpatient admission
			 with a primary diagnosis code for heart failure
C.
Episode
			 duration:
Episodes begin at inpatient admission for heart
			 failure. Episodes end at the latter of 30 days after the date of discharge for
			 the triggering admission or the date of discharge for any inpatient readmission
			 initiated within 30 days of the initial discharge. Episodes shall not exceed 45
			 days post-discharge from the triggering admission.
D.
Episode
			 services:
The episode will include all of the following
			 services rendered within the episode's duration:
1. Inpatient facility and professional fees
			 for the initial hospitalization and for all cause readmissions
2. Emergency or observation care
3. Home health services
4. Skilled nursing facility care due to acute
			 exacerbation of CHF (services not included in episode for patients with SNF
			 care in 30 days prior to episode start)
5. Durable medical equipment
213.200 Principal
			 Accountable Provider
The Principal Accountable Provider (PAP) for an episode is the
				admitting hospital for the trigger hospitalization.
213.300 Exclusions
Episodes meeting one or more of the following criteria will be
				excluded:
A. Beneficiaries do not have
			 continuous Medicaid enrollment for the duration of the episode
B. Beneficiaries under the age of 18 at the
			 time of admission
C. Beneficiaries
			 with any cause inpatient stay in the 30 days prior to the triggering
			 admission
D. Beneficiaries with any
			 of the following comorbidities diagnosed in the period beginning 365 days
			 before the episode start date and concluding on the episode end date:
1) End-Stage Renal Disease;
2) organ transplants;
3) pregnancy;
4) mechanical or left ventricular assist
			 device (LVAD);
5) intra-aortic
			 balloon pump (IABP)
E.
			 Beneficiaries with diagnoses for malignant cancers in the period beginning 365
			 days before the episode start date and concluding on the episode end date. The
			 following types of cancers will not be criteria for episode exclusion: colon,
			 rectum, skin, female breast, cervix uteri, body of uterus, prostate, testes,
			 bladder, lymph nodes, lymphoid leukemia, monocytic leukemia.
F. Beneficiaries who received a pacemaker or
			 cardiac defibrillator in 6 months prior to the start of the episode or during
			 the episode
G. Beneficiaries with
			 any of the following statuses upon discharge:
1) transferred to acute care or inpatient
			 psych facility;
2) left against
			 medical advice;
3)
			 expired
213.400 Adjustments
No adjustments are included in this episode type.
213.500 Quality Measures
A.
Quality measures "to
			 pass":
1. Percent of
			 patients with LVSD who are prescribed an ACEI or ARB at hospital discharge -
			 must meet minimum threshold of 85%.
B.
Quality measures "to
			 track":
1. Frequency of
			 outpatient follow-ups within 7 and 14 days after discharge
2. For qualitative assessments of left
			 ventricular ejection fraction (LVEF), proportion of patients matching:
			 hyperdynamic, normal, mild dysfunction, moderate dysfunction, severe
			 dysfunction
3. Average quantitative
			 ejection fraction value
4. 30-day
			 all cause readmission rate
5.
			 30-day heart failure readmission rate
6. 30-day outpatient observation care rate -
			 utilization metric
The following quality measures require providers to submit data
				through the provider portal: qualitative assessment of LVEF, average
				quantitative ejection fraction value.
213.600
Thresholds for Incentive
			 Payments
A. The acceptable threshold is
			 $6,644.
B. The commendable
			 threshold is $4,722.
C. The gain
			 sharing limit is $3,263.
D. The
			 gain sharing percentage is 50%.
E.
			 The risk sharing percentage is 50%.
213.700
Minimum Case Volume
The minimum case volume is 5 total cases per 12-month
				period.
214.000
TOTAL
			 JOINT REPLACEMENT EPISODES
214.100
Episode Definition/Scope of
			 Services
A.
Episode subtypes:
There are no
			 subtypes for this episode type.
B.
Episode trigger:
A surgical procedure
			 for total hip replacement or total knee replacement
C.
Episode
			 duration:
Episodes begin 30 days prior to the date of
			 admission for the inpatient hospitalization for the total joint replacement
			 surgery and end 90 days after the date of discharge.
D.
Episode
			 services:
The following services are included in the
			 episode:
1. From 30 days prior to the date of
			 admission to the date of the surgery: All evaluation and management, hip- or
			 knee-related radiology and all labs/imaging/other outpatient services
2. During the triggering procedure: all
			 medical, inpatient and outpatient services
3. From the date of the surgery to 30 days
			 after the date of discharge: All cause readmissions, non-traumatic revisions,
			 complications, all follow-up evaluation & management, all emergency
			 services, all home health and therapy, hip/knee radiology and all
			 labs/imaging/other outpatient procedures
4. From 31 days to 90 days after the date of
			 discharge: Readmissions due to infections and complications as well as hip or
			 knee-related follow-up evaluation and management, home health and therapy and
			 labs/imaging/other outpatient procedures
214.200
Principal Accountable
			 Provider
For each episode, the Principal Accountable Provider (PAP) is
				the orthopedic surgeon performing the total joint replacement procedure.
214.300
Exclusions
Episodes meeting one or more of the following criteria will be
				excluded:
A. Beneficiaries who are
			 under the age of 18 at the time of admission
B. Beneficiaries with the following
			 comorbidities diagnosed in the period beginning 365 days before the episode
			 start date and concluding on the date of admission for the joint replacement
			 surgery:
1) select autoimmune diseases;
2) HIV;
3) End-Stage Renal Disease;
4) liver, kidney, heart, or lung transplants;
5) pregnancy;
6) sickle cell disease;
7) fractures, dislocations, open wounds,
			 and/or trauma
C.
			 Beneficiaries with any of the following statuses upon discharge:
1) left against medical advice;
2) expired during hospital stay
D. Beneficiaries who do not have
			 continuous Medicaid enrollment for the duration of the episode
214.400
Adjustments
For the purposes of determining a PAP's performance, the total
				reimbursement attributable to the PAP is adjusted for total joint replacement
				episodes involving a knee replacement to reflect that knee replacements have
				higher average costs than hip replacements. Overtime, Medicaid may add or
				subtract risk or severity factors in line with new research and/or empirical
				evidence.
214.500
Quality Measures
A.
Quality measures "to track":
1. 30-day, all cause readmission
			 rate
2. Frequency of use of
			 prophylaxis against post-op Deep Venous Thrombosis (DVtyPulmonary Embolism (PE)
			 (pharmacologic or mechanical compression)
2. Frequency of post-op DVT/PE
3. 30-day wound infection rate
The following quality measures require providers to submit data
				through the provider portal: use of prophylaxis against post-op Deep Venous
				Thrombosis (DVT)/Pulmonary Embolism (PE), occurrence of post-op Deep Venous
				Thrombosis (DVT)/Pulmonary Embolism (PE)
214.600
Thresholds for
			 Incentive Payments
A. The acceptable
			 threshold is $12,469.
B. The
			 commendable threshold is $8,098.
C.
			 The gain sharing limit is $5,249.
D. The gain sharing percentage is
			 50%.
E. The risk sharing percentage
			 is 50%.
214.700
Minimum Case Volume
The minimum case volume is 5 total cases per 12-month
				period.
ATTACHMENT 4.19-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
				MEDICAL ASSISTANCE PROGRAM STATE
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-INPATIENT HOSPITAL SERVICES
1.
			 Inpatient Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY, EFFICIENCY, AND ECONOMY
V.
APPLICATION:
Complete details
			 including technical information regarding specific quality and reporting
			 metrics, performance thresholds and incentive adjustments are available in the
			 Episodes of Care Medicaid Manual available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx
.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
				the defined scope of services within the following episode(s) of care are
				subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
			 Episodes
ATTACHMENT 4.19-B
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
				MEDICAL ASSISTANCE PROGRAM STATE
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE
2.
a. Outpatient Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
			 EFFICIENCY, AND ECONOMY
V.
APPLICATION:
Complete details including technical information
			 regarding specific quality and reporting metrics, performance thresholds and
			 incentive adjustments are available in the Episodes of Care Medicaid Manual
			 available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx
.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
				the defined scope of services within the following episode(s) of care are
				subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
			 Episodes
5. Physicians' Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
			 EFFICIENCY, AND ECONOMY
V.
APPLICATION:
Complete details including technical information
			 regarding specific quality and reporting metrics, performance thresholds and
			 incentive adjustments are available in the Episodes of Care Medicaid Manual
			 available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx
and also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx
.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Acute Ambulatory Upper Respiratory Infection (URI)
			 Episodes
(2)
Perinatal
			 Care Episodes
(3)
Attention Deficit Hyperactivity Disorder (ADHD) Episodes
Effective for dates of service on or after February 1, 2013,
				the defined scope of services within the following episode(s) of care are
				subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF) Episodes
(2)
Total Joint Replacement
			 Episodes
23. Any other medical care and any other type
			 of remedial care recognized under State law, specified by the Secretary.
e. Emergency Hospital Services
A.
INCENTIVES TO IMPROVE CARE QUALITY,
			 EFFICIENCY, AND ECONOMY
V.
APPLICATION:
Complete details including technical information
			 regarding specific quality and reporting metrics, performance thresholds and
			 incentive adjustments are available in the Episodes of Care Medicaid Manual
			 available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx
.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
				the defined scope of services within the following episode(s) of care are
				subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF)
			 Episodes
f. Critical Access Hospitals (CAH)
A.
INCENTIVES TO IMPROVE CARE QUALITY,
			 EFFICIENCY, AND ECONOMY
V.
APPLICATION:
Complete details including technical information
			 regarding specific quality and reporting metrics, performance thresholds and
			 incentive adjustments are available in the Episodes of Care Medicaid Manual
			 available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspxand
also at the Arkansas Health Care Payment Improvement Initiative website at
http://www.paymentinitiative.org/Pages/default.aspx
.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Perinatal Care Episodes
Effective for dates of service on or after February 1, 2013,
				the defined scope of services within the following episode(s) of care are
				subject to incentive adjustments:
(1)
Congestive Heart Failure (CHF)
			 Episodes