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 354.1445 - Potentially Preventable Readmissions

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 meet outcome and process measures relative
					 to all Texas Medicaid and CHIP hospitals regarding the rates of potentially
					 preventable events.
(b)
					 Definitions.
(1) Actual-to-Expected Ratio--A
					 ratio that measures the impact of potentially preventable readmissions (PPRs)
					 by deriving an actual hospital rate compared to an expected hospital rate based
					 on a methodology defined by HHSC. HHSC may use cost of PPR as a factor in
					 weighting PPRs and in calculating PPR Actual-to-Expected Ratio.
(2) Adjustment time period--The state fiscal
					 year (September through August) that a hospital's claims are adjusted in
					 accordance with subsection (f) 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) Candidate admission--An admission that is
					 at risk of a PPR.
(5) Case-mix--A
					 measure of the clinical characteristics of patients treated during the
					 reporting time period and measured using APR DRG or its replacement
					 classification system, severity of illness, patient age, and the presence of a
					 major mental health or substance abuse comorbidity.
(6) Claims during the reporting time
					 period--Includes Medicaid traditional fee-for-service (FFS), Children's Health
					 Insurance Program or CHIP, and managed care inpatient hospital claims filed for
					 reimbursement by a hospital that:
(A) had a
					 date of admission occurring within the reporting period;
(B) were adjudicated and approved for payment
					 during the reporting period and the six-month grace period that immediately
					 followed, except for claims that had zero inpatient days;
(C) were not claims for patients who are
					 covered by Medicare;
(D) were not
					 claims for individuals classified as undocumented immigrants; and
(E) were not subject to other exclusions as
					 determined by HHSC.
(7)
					 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.
(8) Clinically related--A requirement that
					 the underlying reason for readmission be plausibly related to the care rendered
					 during or immediately following the initial admission. A clinically related
					 readmission occurs within a specified readmission time interval resulting from
					 the process of care and treatment during the initial admission or from a lack
					 of post admission follow-up, but not from unrelated events occurring after the
					 initial admission.
(9) HHSC--The
					 Health and Human Services Commission or its designee.
(10) 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.
(11) Initial admission--A
					 candidate admission followed by one or more readmissions that are clinically
					 related.
(12) Managed care
					 organization (MCO)--A provider or organization under contract with HHSC to
					 provide services to Medicaid or CHIP recipients using a health care delivery
					 system or dental services delivery system in which provider or organization
					 coordinates the patient's overall care.
(13) Medicaid program--The medical assistance
					 program established under Chapter 32, Texas Human Resources Code.
(14) 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 these
					 events, which are more fully defined in §
												RSA 354.1070 of this
					 title.
(15) Potentially preventable
					 readmission (PPR)--A return hospitalization of a person within a period
					 specified by HHSC that may have resulted from deficiencies in the care or
					 treatment provided to the person during a previous hospital stay or from
					 deficiencies in post-hospital discharge follow-up. The term does not include a
					 hospital readmission necessitated by the occurrence of unrelated events after
					 the discharge. The term includes the readmission of a person to a hospital for:
(A) the same condition or procedure for which
					 the person was previously admitted;
(B) an infection or other complication
					 resulting from care previously provided;
(C) a condition or procedure that indicates
					 that a surgical intervention performed during a previous admission was
					 unsuccessful in achieving the anticipated outcome; or
(D) another condition or procedure of a
					 similar nature, as determined by HHSC.
(16) Readmission chain--A sequence of PPRs
					 that are all clinically related to the Initial Admission. A readmission chain
					 may contain an Initial Admission and only one PPR, or may contain multiple PPRs
					 following the Initial Admission.
(17) Reporting time period--The period of
					 time that includes hospital claims that are assessed for PPRs. This may be a
					 state fiscal year (September through August) or other specified time frame as
					 determined by HHSC. PPR 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.
(18)
					 Safety-net hospital--As defined in §
												RSA
					 355.8052 of this title (relating to Inpatient
					 Hospital Reimbursement).