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 5.3 - Official Medical Fee Schedule › Section 9789.22 - Payment of Inpatient Hospital Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Unless otherwise provided by applicable
					 provisions of this fee schedule, the maximum payment for inpatient medical
					 services shall be determined by multiplying 1.20 by the product of the
					 hospital's composite factor and the applicable DRG weight and by making any
					 adjustments required by this fee schedule. The fee determined under this
					 subdivision shall be a global fee, constituting the maximum reimbursement to a
					 hospital for inpatient medical services not exempted under this section.
					 However, preadmission services rendered by a hospital more than 24 hours before
					 admission are separately reimbursable.
(b) The maximum payment for inpatient medical
					 services includes reimbursement for all of the inpatient operating costs
					 specified in Title 42, Code of Federal Regulations, Section
					 412.2(c), which is
					 incorporated by reference and will be made available upon request to the
					 Administrative Director, and the inpatient capital-related costs specified in
					 Title 42, Code of Federal Regulations, Section
					 412.2(d), which is
					 incorporated by reference and will be made available upon request to the
					 Administrative Director. See Section
					 9789.25(a) for the
					 Code of Federal Regulations reference for the effective date, revisions, and
					 amendments by date of discharge.
(c) The maximum payment shall include the
					 cost items specified in Title 42, Code of Federal Regulations, Section
					 412.2(e)(1), (2), (3), and
					 (5), which in incorporated by reference and
					 will be made available upon request to the Administrative Director. The maximum
					 allowable fees for cost item set forth at
					 42 C.F.R. Section
					 412.2(e)(4), "the
					 acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines
					 (or multivisceral organ) incurred by approved transplantation centers," shall
					 be based on the documented paid cost of procuring the organ or tissue. See
					 Section 9789.25(a) for the
					 Code of Federal Regulations reference for the effective date, revisions, and
					 amendments by date of discharge.
(d) The maximum payment shall cover all items
					 and services provided to hospital inpatients other than professional services
					 provided by physicians and other practitioners that are payable under the
					 Official Medical Fee Schedule -- physicians fee schedule section in effect at
					 the time the service was rendered (see Section
					 9789.111(a)).
					 Except for services paid under the physicians fee schedule, all billing for
					 payments shall originate from hospitals and payment may be made only to
					 hospitals for the covered items and services, including any spinal device
					 separately payable under Sections
					 9789.22(g).
(e) Hospitals billing for fees under this
					 section shall be submitted in accordance with the e-billing regulations
					 beginning with Section
					 9792.5.0 or the standardized paper
					 billing regulations beginning with Section
					 9792.5.2.
(f)
(1)
					 Cost Outlier cases.
(A) Unless otherwise
					 provided, except for inpatient services provided by a hospital transferring an
					 inpatient to another hospital or post-acute care provider in accordance with
					 section 9789.22(j),
					 inpatient services for cost outlier cases, shall be reimbursed as follows:
Step 1: Determine the Inpatient Hospital Fee Schedule
						maximum payment amount (DRG weight x 1.2 x hospital specific composite
						factor).
Step 2: Determine costs according to section
						9789.21(f).
Step 3: Determine outlier threshold. Outlier threshold =
						(Inpatient Hospital Fee Schedule payment amount + hospital specific outlier
						factor + any new technology pass-through payment determined under Section
						9789.22(h) + any
						additional allowance for spinal devices under Section
						9789.22(g)(2)).
(B) Inpatient services provided by a hospital
					 transferring an inpatient to another hospital subject to section
					 9789.22(j)(1) for
					 cost outlier cases, shall be reimbursed as follows:
Step 1: Determine the Inpatient Hospital Fee Schedule
						maximum payment amount according to section
						9789.22(j)(1).
Step 2: Determine costs according to section
						9789.21(f).
Step 3: Determine outlier threshold. Outlier threshold =
						((Inpatient Hospital Fee Schedule payment amount + hospital specific outlier
						factor) / geometric length of stay for the DRG x (the actual length of stay for
						the case + one day)) + any new technology pass-through payment + any additional
						allowance for spinal devices under Section
						9789.22(g)(2). The
						outlier threshold determined under this subdivision shall not exceed the amount
						determined under subdivision (A) of this section.
Inpatient services provided by the receiving hospital
						(final discharging hospital) subject to section
						9789.22(j)(1) for
						cost outlier cases shall be reimbursed according to subdivision (A) of this
						section.
(C) Inpatient
					 services provided by a hospital transferring an inpatient to a post-acute care
					 provider subject to section
					 9789.22(j)(2)(A)
					 for cost outlier cases, shall be reimbursed according to subdivision
					 (B).
(D) Inpatient service
					 discharges assigned to a special pay DRG provided by a hospital transferring an
					 inpatient to a post-acute care provider subject to section
					 9789.22(j)(2)(B)
					 for cost outlier cases, shall be reimbursed as follows:
Step 1: Determine the Inpatient Hospital Fee Schedule
						maximum payment amount according to section
						9789.22(j)(2)(B).
Step 2: Determine costs according to section
						9789.21(f).
Step 3: Determine outlier threshold. Outlier threshold =
						(Inpatient Hospital Fee Schedule payment amount + hospital specific outlier
						factor) x 0.5 + ((Inpatient Hospital Fee Schedule payment amount + hospital
						specific outlier factor) x 0.5 / the geometric mean length of stay x the actual
						length of stay plus one day) + any new technology pass-through payment
						determined under Section
						9789.22(h) + any
						additional allowance for spinal devices under Section
						9789.22(g)(2). The
						outlier threshold determined under this subdivision shall not exceed the amount
						determined under subdivision (A) of this section.