Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1050 - Hospital services definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and abbreviations, those found in
				  chapter 182-500 WAC, Medical definitions, and definitions and abbreviations
				  found in other sections of this chapter apply to this chapter. When a term is
				  not defined in this chapter, other agency or agency's designee WAC, or state or
				  federal law, the medical definitions found in
Taber's Cyclopedic
				  Medical Dictionary
apply.
"Accommodation costs"
- The expenses incurred by
				  a hospital to provide its patients services for which a separate charge is not
				  customarily made. These expenses include, but are not limited to, room and
				  board, medical social services, psychiatric social services, and the use of
				  certain hospital equipment and facilities.
"Accredited"
or
"accreditation"
- A
				  term used by nationally recognized health organizations, such as the commission
				  on accreditation of rehabilitation facilities (CARF), to indicate a facility
				  meets both professional and community standards of medical care.
"Acute"
- A medical condition of severe
				  intensity with sudden onset. For the purposes of the acute physical medicine
				  and rehabilitation (Acute PM&R) program, acute means an intense medical
				  episode, not longer than three months.
"Acute care"
- Care provided for patients who
				  are not medically stable or have not attained a satisfactory level of
				  rehabilitation. These patients require frequent monitoring by a health care
				  professional to maintain their health status.
"Acute physical medicine and rehabilitation (acute
				  PM&R)"
- A comprehensive inpatient rehabilitative program
				  coordinated by an interdisciplinary team at an agency-approved rehabilitation
				  facility. The program provides twenty-four-hour specialized nursing services
				  and an intense level of therapy for specific medical conditions for which the
				  client shows significant potential for functional improvement. Acute PM&R
				  is a twenty-four hour inpatient comprehensive program of integrated medical and
				  rehabilitative services provided during the acute phase of a client's
				  rehabilitation.
"Administrative day"
or
"administrative
				  days"
- One or more days of a hospital stay in which an acute inpatient
				  or observation level of care is not medically necessary, and a lower level of
				  care is appropriate.
"Administrative day rate"
- The agency's
				  statewide medicaid average daily nursing facility rate.
"Aggregate cost"
- The total cost or the sum of
				  all constituent costs.
"Aggregate operating cost"
- The total cost or
				  the sum of all operating costs.
"All-patient DRG grouper (AP-DRG)"
- A computer
				  software program that determines the medical and surgical diagnosis-related
				  group (DRG) assignments used by the agency for inpatient admissions between
				  August 1, 2007, and June 30, 2014.
"All-patient refined DRG grouper (APR-DRG)"
- A
				  computer software program that determines the medical and surgical
				  diagnosis-related group (DRG) assignments used by the agency for inpatient
				  admissions on and after July 1, 2014.
"Allowable"
- The calculated amount for payment,
				  after exclusion of any "nonallowed service or charge," based on the applicable
				  payment method before final adjustments, deductions, and add-ons.
"Allowed amount"
- The initial calculated amount
				  for any procedure or service, after exclusion of any "nonallowed service or
				  charge," that the agency allows as the basis for payment computation before
				  final adjustments, deductions, and add-ons.
"Allowed charges"
- The total billed charges for
				  allowable services.
"Allowed covered charges"
- The total billed
				  charges for services minus the billed charges for noncovered services, denied
				  services, or both.
"Ambulatory payment classification (APC)"
- A
				  grouping that categorizes outpatient visits according to the clinical
				  characteristics, the typical resource use, and the costs associated with the
				  diagnoses and the procedures performed.
"Ambulatory surgery"
- A surgical procedure that
				  is not expected to require an inpatient hospital admission.
"Ancillary services"
- Additional or supporting
				  services provided by a hospital to a client during the client's hospital stay.
				  These services include, but are not limited to: Laboratory, radiology, drugs,
				  delivery room, operating room, postoperative recovery rooms, and other special
				  items and services.
"Appropriate level of care"
- The level of care
				  required to best manage a client's illness or injury based on:
(1) The severity of illness and the intensity of services
				  required to treat the illness or injury; or
(2) A condition-specific episode of care.
(1) Health, financial, and billing records pertaining to
				  billed services paid by the agency through Washington apple health, by a person
				  not employed or affiliated with the provider, to verify the service was
				  provided as billed and was allowable under program regulations; and
(2) Financial, statistical, and health records, including
				  mathematical computations and special studies conducted supporting the medicare
				  cost report (Form 2552-96 and 2552-10 or successor form), submitted to the
				  agency to establish program rates for payment to hospital providers.
(1) Is generally accepted by the medical profession as
				  effective and appropriate; and
(2) Has been approved by the federal Food and Drug
				  Administration (FDA) or other requisite government body if approval is
				  required.
(1) Discharges from a hospital or distinct unit;
(2) Dies in a hospital or distinct unit;
(3) Transfers from a hospital or distinct unit as an acute
				  care transfer; or
(4) Transfers from the hospital or distinct unit to a
				  designated psychiatric unit or facility, or a designated acute rehabilitation
				  unit or facility.
(1) Ventilator weaning care; or
(2) Care for a client who has:
(a) Chronic open wounds that require on-site wound care
				  specialty services and daily assessments and/or interventions; and
(b) At least one comorbid condition (such as chronic renal
				  failure requiring hemodialysis).
(1) Ventilator care for a client who is ventilator-dependent
				  and is not weanable and has complex medical needs; or
(2) Care for a client who:
(a) Has a tracheostomy;
(b) Requires frequent respiratory therapy services for
				  complex airway management and has the potential for decannulation; and
(c) Has at least one comorbid condition (such as
				  quadriplegia).
(1) Prevents or corrects physical deformity or malfunction;
				  or
(2) Supports a weak or deformed portion of the body.
(1) Artificially replace a missing portion of the
				  body;
(2) Prevent or correct physical deformity or malfunction;
				  or
(3) Support a weak or deformed portion of the body.
"Psychiatric hospital"
- A medicare-certified
				  distinct psychiatric unit, a medicare-certified psychiatric hospital, or a
				  state-designated pediatric distinct psychiatric unit in a medicare-certified
				  acute care hospital. Eastern state hospital and western state hospital are
				  excluded from this definition.
"Public hospital district"
- A hospital district
				  established under chapter 70.44 RCW.
"Ratable"
- A factor used to calculate inpatient
				  payments for state-administered programs.
"Ratio of costs-to-charges (RCC)"
- A method
				  used to pay hospitals for some services exempt from the DRG payment method. It
				  also refers to the percentage applied to a hospital's allowed covered charges
				  for medically necessary services to determine estimated costs, as determined by
				  the agency, and payment to the hospital for some DRG-exempt services.
"Rebasing"
- The process used by the agency to
				  update hospital payment policies, related variables (rates, factors,
				  thresholds, multipliers, and caps), and system processes (edits, adjudication,
				  grouping, etc.).
"Recalibration"
- The process of recalculating
				  DRG relative weights using historical data.
"Rehabilitation units"
- Specifically identified
				  rehabilitation hospitals and designated rehabilitation units of hospitals that
				  meet agency and medicare criteria for distinct rehabilitation units.
"Relative weights"
- See
"DRG relative
				  weights."
"Reserve days"
- The days beyond the ninetieth
				  day of hospitalization of a medicare patient for a benefit period or incidence
				  of illness. See also
"lifetime hospitalization reserve."
"Revenue code"
- A nationally assigned coding
				  system for billing inpatient and outpatient hospital services, home health
				  services, and hospice services.
"Room and board"
- Routine supplies and services
				  provided to a client during the client's hospital stay. This includes, but is
				  not limited to, a regular or special care hospital room and related
				  furnishings, room supplies, dietary and bedside nursing services, and the use
				  of certain hospital equipment and facilities.
"Rural health clinic"
- See WAC
				  182-549-1100.
"Rural hospital"
- An acute care health care
				  facility capable of providing or assuring availability of inpatient and
				  outpatient hospital health services in a rural area.
"Semi-private room rate"
- A rate customarily
				  charged for a hospital room with two to four beds; this charge is generally
				  lower than a private room rate and higher than a ward room. See also
"multiple occupancy rate."
"Significant procedure"
- A procedure, therapy,
				  or service provided to a client that constitutes one of the primary reasons for
				  the visit to the health care professional, and represents a substantial portion
				  of the resources associated with the visit.
"Specialty hospitals"
- Children's hospitals,
				  psychiatric hospitals, cancer research centers or other hospitals which
				  specialize in treating a particular group of patients or diseases.
"Spenddown"
- See chapter 182-519 WAC.
"State plan"
- The plan filed by the agency with
				  CMS, Department of Health and Human Services (DHHS), outlining how the state
				  will administer medicaid and CHIP services, including the hospital
				  program.
"Status indicator (SI)"
- A code assigned to
				  each medical procedure or service by the agency that contributes to the
				  selection of a payment method.
"Subacute care"
- Care provided to a client
				  which is less intensive than that given at an acute care hospital. Skilled
				  nursing, nursing care facilities and other facilities provide subacute care
				  services.
"Substance use disorder (SUD)"
- See
				  RCW
				  71.05.020.
"Survey"
- An inspection or review conducted by
				  a federal, state, or private agency to evaluate and monitor a facility's
				  compliance with program requirements.
"Swing bed"
- An inpatient hospital bed
				  certified by CMS for either acute inpatient hospital or skilled nursing
				  services.
"Swing-bed day"
- A day in which a client is
				  receiving skilled nursing services in a hospital-designated swing bed at the
				  hospital's census hour.
"Total patient days"
- All patient days in a
				  hospital for a given reporting period, excluding days for skilled nursing,
				  nursing care, and observation days.
"Transfer"
- To move a client from one acute
				  care setting to a higher level acute care setting for emergency care or to a
				  post-acute, lower level care setting for ongoing care.
"Transferring hospital"
- The hospital or
				  distinct unit that transfers a client to another acute care or subacute
				  facility or distinct unit, or to a nonhospital setting.
"UB-04"
- The uniform billing document required
				  for use nationally by hospitals, nursing facilities, hospital-based skilled
				  nursing facilities, home health agencies, and hospice agencies in billing for
				  services provided to patients. This document includes the current national
				  uniform billing data element specifications developed by the National Uniform
				  Billing Committee and approved and modified by the Washington state payer group
				  or the agency.
"Vendor rate increase"
- An adjustment
				  determined by the legislature, that may be used to periodically increase rates
				  for payment to vendors, including health care providers, that do business with
				  the state.
"Washington apple health program"
- Any health
				  care program administered through the medicaid agency.
11-14-075, recodified as §
											182-550-1050, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-052, §
					 388-550-1050, filed 6/28/07, effective 8/1/07; 04-20-057, § 388-550-1050,
					 filed 10/1/04, effective 11/1/04. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090, and
					 Public Law
					 104-191. 03-19-043, § 388-550-1050, filed
					 9/10/03, effective 10/11/03. Statutory Authority:
					 RCW
					 74.08.090 and
					 42 U.S.C.
					 1395 x(v),
					 42 C.F.R.
					 447.271, .11303, and .2652. 01-16-142, §
					 388-550-1050, filed 7/31/01, effective 8/31/01. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 42 U.S.C.
					 1395 x(v),
					 42 C.F.R.
					 447.271, .11303 and .2652. 99-14-039, §
					 388-550-1050, filed 6/30/99, effective 7/1/99. Statutory Authority:
					 RCW
					 74.08.090,
					 42 USC
					 1395 x(v),
					 42 C.F.R.
					 447.271, 447.11303, and 447.2652. 99-06-046,
					 § 388-550-1050, filed 2/26/99, effective 3/29/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-1050, filed 12/18/97,
					 effective 1/18/98.