Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 152 - HOSPITAL REIMBURSEMENT CHANGES › Section 152.300 - Adjustment for Potentially Preventable Readmissions

Current through Register Vol. 48, No. 28, July 12, 2024
a) Notwithstanding any provision set forth in
			 89 Ill. Adm. Code 148 or 149 and unless otherwise stated in this Section, the
			 changes described in this Section will be effective January 1, 2013.
b) For clean claims received on or after
			 January 1, 2013, rates of payment to hospitals that have an excess number of
			 readmissions, as defined in accordance with the criteria set forth in
			 subsection (d), as determined by a risk adjusted comparison of the actual and
			 targeted number of readmissions in a hospital as described by subsection (e),
			 shall be reduced in accordance with subsection (f).
c) Definitions. For purposes of this Section,
			 the following terms are defined in this subsection (c). For State fiscal year
			 2013, the Potentially Preventable Readmission (PPR) methodology, version 27 of
			 the definitions manual applicable to the 3M Potentially Preventable
			 Readmissions Grouping Software created and maintained by the 3M Corporation
			 will be used by HFS to process admissions data and determine whether an
			 admission is a Potentially Preventable Readmission. This version is available
			 by registering at the following link:
https://support.3mhis.com/app/answers/detail/a_id/4133/kw/PPR
.
			 For the State fiscal year 2014 PPR methodology, version 29 of the definitions
			 manual applicable to the PPR software created and maintained by the 3M
			 Corporation will be used by HFS to process admissions data and determine
			 whether an admission is a Potentially Preventable Admission. This version is
			 available by registering at the link referenced above. Beyond State fiscal year
			 2014, the version that the Department will utilize will be updated in rule as
			 soon as the information becomes available to the Department. Except when other
			 definitions and criteria applicable to PPR are specified in this Section, the
			 methodology applied by the 3M PPR Grouping Software and contained in the
			 Potentially Preventable Readmissions Classification System Methodology Overview
			 (GRP-139, May 2008, no later amendments or editions included) published by 3M
			 Health Information Systems, 575 West Murray Blvd., Salt Lake City UT 84123, and
			 accessible at
http://www2.illinois.gov/hfs/SiteCollectionDocuments/3MPotentiallyPreventableReadmissions.pdf
,
			 is incorporated by reference.
1) "Potentially
			 Preventable Readmission" or "PPR" shall mean a readmission meeting the
			 readmission criteria in subsection (d) that follows a prior discharge from a
			 hospital within 30 days and that is clinically-related to the prior hospital
			 admission.
2) "Hospital" shall mean
			 a hospital as defined in 89 Ill. Adm. Code
			 148.25(b).
3) "Base Year" shall mean State fiscal year
			 2010 and it is the initial data year the Department used to calculate the
			 statewide average PPR rate. Each hospital Current Year is compared to the Base
			 Year to measure the hospital's PPR performance over time.
4) "Current Year" shall mean the State fiscal
			 year in which Targeted Rate of Readmission is set for hospitals to achieve
			 their Targeted Rates of Readmission.
5) "Data Year" shall mean the most recent
			 fully adjudicated claims data in a State fiscal year available to the
			 Department, which is used to calculate the Actual Rate of Readmission and the
			 Targeted Rate of Readmission for each hospital.
6) "Clean Claim" shall mean a claim as
			 defined in
			 42 CFR
			 447.45(b).
7) "Clinically Related" shall mean that the
			 underlying reason for readmission is plausibly related to the care rendered
			 during a prior hospital admission. A clinically-related readmission results
			 from the process of care and treatment provided during the prior admission
			 (e.g., readmission for a surgical wound infection) or from a lack of
			 post-admission follow up (e.g., lack of follow-up care arrangements with a
			 primary physician) rather than from unrelated events that occurred after the
			 prior admission (such as a broken leg due to trauma) within a specified
			 readmission time interval.
8)
			 "Initial Admission" shall mean an admission to a hospital that is followed by a
			 subsequent readmission or readmissions within 30 days that are determined by
			 the 3M Corporation's PPR methodology to be clinically related.
9) "Only Admission" shall mean an admission
			 without an associated readmission.
10) "Potentially Preventable Readmission
			 Chain" or "PPR Chain" shall mean an initial admission occurring at a hospital
			 that is followed by one or more clinically-related PPRs. The PPRs may occur at
			 the same hospital or a different hospital.
11) "Qualifying Admission" shall mean the
			 number of PPR Chains plus the number of "Only Admissions", but specifically
			 excludes the admissions detailed in subsection (d)(2).
12) "Actual Rate" shall mean the number of
			 PPR Chains for a hospital divided by the total number of qualifying admissions
			 for the hospital.
13) "Targeted
			 Rate of Readmissions" shall mean a risk adjusted readmission rate for each
			 hospital that accounts for the severity of illness, APR-DRG, presence of
			 behavioral health issues, and age of patient at the time of discharge preceding
			 the readmission.
14) "Excess Rate
			 of Readmission" shall mean the difference between the actual rate of
			 readmission and the targeted rate of readmission for each hospital.
15) "Behavioral Health", for the purposes of
			 risk adjustments, shall mean an admission that includes a secondary diagnosis
			 of a major behavioral health related condition, including, but not limited to,
			 mental disorders, chemical dependency and substance abuse.
16) As of August 1, 2013,
			 "Pediatric/Behavioral Health Factor" shall mean a factor that is a calculation
			 of PPR for both children and adults with and without a secondary diagnosis of
			 Behavioral Health. This is a risk adjustment factor. This factor is multiplied
			 by a hospital's Actual Rate of PPR at the service level before it is compared
			 to the statewide average rate of PPR in order to calculate the hospital's
			 Actual Rate of readmission. There are three categories of factors that are
			 calculated and within each category there are three factors that are calculated
			 for a total of nine factors. The categories include pediatric at a non-Tier I
			 PICU Facility, a pediatric at a Tier I PICU Facility and an adult. Within each
			 category, the three factor calculations include a primary diagnosis of
			 non-behavioral health with no presence of behavioral health, a primary
			 diagnosis of non behavioral health with a secondary diagnosis of behavioral
			 health and a primary diagnosis of behavioral health. For example, Tier I PICU
			 Facilities treat higher acuity children and therefore have a higher expected
			 rate of readmission than those children with the same diagnosis treated at the
			 non-Tier I PICU Facilities. By applying this factor, it risk-adjusts the
			 hospital's PPR rate to account for the variance in readmission rates for the
			 different categories.
17) As of
			 August 1, 2013, "Tier I Pediatric Intensive Care Unit" or "PICU" shall mean, a
			 hospital that is either freestanding or has a Distinct Part Unit having
			 pediatric trauma units and provides two or three of the following sets of
			 procedures: pediatric transplants, Extracorporeal Membrane Oxygenation (ECMO),
			 and complex pediatric cardiac surgeries.