Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 35 - REIMBURSEMENT ADJUSTMENTS FOR POTENTIALLY PREVENTABLE EVENTS › Section 354.1446 - Potentially Preventable Complications

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Introduction. The Health and Human Services Commission (HHSC) may reward or
					 penalize a hospital under this section based on the hospital's performance with
					 respect to exceeding or failing to achieve outcome and process measures
					 relative to all Texas Medicaid and CHIP hospitals that address the rates of
					 potentially preventable events.
(b)
					 Definitions.
(1) Actual to Expected
					 Ratio--The ratio of actual potentially preventable complications (PPCs) within
					 an inpatient stay compared with expected PPCs within an inpatient stay, where
					 the expected number depends on the all patient refined diagnosis related group
					 at the time of admission (APR DRG or its replacement classification system) is
					 adjusted for the patient's severity of illness. HHSC, at its discretion,
					 determines the relative weights of PPCs when calculating the actual to expected
					 ratio. Expected PPC results calculation is based on the statewide norms and is
					 calculated from Medicaid traditional fee-for-service (FFS), Children's Health
					 Insurance Program or CHIP, and, if available, managed care data.
(2) Adjustment time period--The state fiscal
					 year (September through August) that a hospital's claims are adjusted in
					 accordance with subsection (f) or (g)(5) of this section. Adjustments will be
					 done on an annual basis.
(3) All
					 Patient Refined Diagnosis Related Group (APR DRG)--A diagnosis and procedure
					 code classification system for inpatient services.
(4) Case-mix--A measure of the clinical
					 characteristics of patients treated during the reporting time period based on
					 diagnosis and severity of illness. "Higher" case-mix refers to sicker patients
					 who require more hospital resources.
(5) Children's Health Insurance Program or
					 CHIP or Program--The Texas State Children's Health Insurance Program
					 established under Title XXI of the federal Social Security Act (42 U.S.C.
					 Chapter 7, Title XXI) and Chapters 62 and 63 of the Texas Health and Safety
					 Code.
(6) Inpatient claims during
					 the reporting time period--Includes Medicaid traditional FFS, CHIP, and, if
					 available, managed care data for inpatient hospital claims filed for
					 reimbursement by a hospital that:
(A) had a
					 date of admission occurring within the reporting time period;
(B) were adjudicated and approved for payment
					 during the reporting time period and the six-month grace period that
					 immediately followed, except for such claims that had zero inpatient
					 days;
(C) were not inpatient stays
					 for patients who are covered by Medicare;
(D) were not claims for patients diagnosed
					 with major metastatic cancer, organ transplants, human immunodeficiency virus
					 (HIV), or major trauma; and
(E)
					 were not subject to other exclusions as determined by HHSC.
(7) HHSC--The Health and Human
					 Services Commission or its designee.
(8) Hospital--A public or private institution
					 licensed under Chapter 241 or Chapter 577, Texas Health and Safety Code,
					 including a general or special hospital as defined by §
												RSA
					 241.003, Texas Health and Safety
					 Code.
(9) Managed care organization
					 (MCO)--Managed care is a health care delivery system or dental services
					 delivery system in which the overall care of a patient is coordinated by or
					 through a single provider or organization. MCO refers to such a provider or
					 organization under contract with HHSC to provide services to Medicaid
					 recipients.
(10) Medicaid
					 program--The medical assistance program established under Chapter 32, Texas
					 Human Resources Code.
(11)
					 Norm--The Texas statewide average or the standard by which hospital PPC
					 performance is compared.
(12)
					 Potentially preventable complication (PPC)--A harmful event or negative outcome
					 with respect to a person, including an infection or surgical complication,
					 that:
(A) occurs after the person's admission
					 to an inpatient acute care hospital; and
(B) may have resulted from the care, lack of
					 care, or treatment provided during the hospital stay rather than from a natural
					 progression of an underlying disease.
(13) Potentially preventable event (PPE)--A
					 potentially preventable admission, a potentially preventable ancillary service,
					 a potentially preventable complication, a potentially preventable emergency
					 room visit, a potentially preventable readmission, or a combination of those
					 events, which are more fully defined in §
												RSA 354.1070 of this
					 title.
(14) Present on Admission
					 (POA) Indicators--A coding system that requires hospitals to accurately submit
					 principal and secondary diagnoses that are present at the time of admission.
					 POA codes are essential for the accurate calculation of PPC rates and consist
					 of the current coding set approved by CMS.
(15) Reporting time period--The period of
					 time that includes hospital claims that are assessed for PPCs. This may be a
					 state fiscal year (September through August) or other specified time frame as
					 determined by HHSC. PPC Reports will consist of statewide and hospital-specific
					 reports and will be done at least on an annual basis, using the most complete
					 data period available to HHSC.
(16)
					 Safety-net hospital--As defined in §
												RSA
					 355.8052 of this title (relating to Inpatient
					 Hospital Reimbursement).