Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter C - UTILIZATION REVIEW › Section 371.203 - TMRP Review Process

Current through Reg. 49, No. 28; July 12, 2024
(a) The TMRP review
				  process includes:
(1) Admission review to
				  evaluate the medical necessity of the admission. For purposes of the TMRP
				  reviews, medical necessity means the patient has a condition requiring
				  treatment that can be safely provided only in the inpatient setting.
(2) Diagnosis-related group (DRG) validation
				  to confirm documentation in the medical record of the critical elements
				  necessary to assign a DRG. The hospital staff is responsible and held
				  accountable for the accuracy of the required critical elements. Those elements
				  are age, sex, discharge status, admission date, discharge date, principal
				  diagnosis, principal and secondary procedures, any complications or
				  comorbidities (secondary diagnoses), and Present on Admission (POA) indicators.
(A) POA review validates the POA indicator
				  assigned to the principal and secondary diagnoses codes reported on claim
				  forms. If it is determined that the principal and/or secondary diagnoses were
				  not present at the time the order for inpatient admission occurs, HHSC revises
				  the POA indicator for the diagnosis code. Conditions that develop during an
				  outpatient encounter, including emergency department, observation, or
				  outpatient surgery, are considered POA.
(B) DRG validation confirms that the
				  principal and secondary diagnoses and procedures are sequenced correctly. The
				  principal diagnosis is the diagnosis (condition) established after study to be
				  chiefly responsible for occasioning the admission of the patient to the
				  hospital for care. The secondary diagnoses are conditions that affect the
				  patient care in terms of requiring: clinical evaluation, therapeutic treatment,
				  diagnostic procedures, extended length of hospital stay, increased nursing care
				  and/or monitoring, or in the case of a newborn, conditions the physician deems
				  to have clinically significant implications for future health care needs. If
				  the principal diagnosis, secondary diagnoses, or procedures are not
				  substantiated in the medical record, are not sequenced correctly, or have been
				  omitted, codes may be deleted, changed, or added.
(C) When the correct diagnosis and procedure
				  coding and sequencing have been determined, the information is entered into the
				  applicable version of the Grouper software for a DRG assignment. CMS-approved
				  DRG Grouper software considers the required critical elements and determines
				  the final DRG assignment. If the DRG validation process results in deletions,
				  changes, or additions to the critical elements and these changes cause the DRG
				  to be reassigned, HHSC directs the claims administrator to adjust the payment
				  to the hospital accordingly.
(3) Quality of care review to assess whether
				  the care provided meets generally accepted standards of medical and hospital
				  care practices or puts the patient at risk of unnecessary injury, disease, or
				  death. Quality of care review includes the use of discharge screens and generic
				  quality screens. If quality of care issues are identified, physician
				  consultants under contract with HHSC and of the specialty related to the care
				  provided determine possible clinical recommendations or corrective
				  actions.
(4) Readmission review to
				  evaluate each admission on its individual merits and determine if the second or
				  subsequent admissions resulted from a premature discharge or were required to
				  provide services that should have been provided in a previous
				  admission.
(5) Day outlier review,
				  which includes DRG validation, verifies the medical necessity of each day of
				  the admission.
(6) Cost outlier
				  review to verify that services billed were medically necessary, ordered by a
				  physician or non-physician provider, rendered and billed appropriately, and
				  substantiated in the medical record.