Ind. Admin. Code tit. 405, r. 1-10.5-5 – Health care-acquired conditions and other provider-preventable conditions

Sec. 5. (a) This section applies to the following:

(1) Payment for inpatient stays reimbursed according to the DRG and level-of-care methodologies.
(2) All inpatient hospital facility reimbursement provisions, including the following:
1. (A) Medicaid supplemental payments.
2. (B) Medicaid enhanced payments.
3. (C) Medicaid disproportionate share hospital payments.

(b) The DRG to be assigned for an inpatient stay shall be a DRG that does not result in higher payment based on the presence of a health care-acquired condition that was not present on the date of admission. If a health care-acquired condition is not present on the date of admission, the discharge will be assigned to a DRG as though the health care-acquired condition was not present.

(c) Secondary diagnoses that are present on the date of admission must be designated as such as part of the claim information submitted by an inpatient hospital facility in order for Medicaid reimbursement to be made. Secondary diagnoses that are not present on the date of admission must be designated as such as part of the claim information submitted by an inpatient hospital facility in order for the diagnoses to be excluded for purposes of assigning the claim to a DRG.

(d) For purposes of this section, a "health care-acquired condition" means a condition associated with a diagnosis code selected by the Secretary of the U.S. Department of Health and Human Services pursuant to 42 U.S.C. 1395ww(d)(4)(D) and 42 CFR 447.26(b) and in effect on the date of admission.

(e) The state shall not pay for other provider-preventable conditions, as defined at 42 CFR 447.26(b).

(Office of the Secretary of Family and Social Services; 405 IAC 1-10.5-5; filed Aug 28, 2009, 3:38 p.m.: 20090923-IR-405090202FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Nov 8, 2013, 2:56 p.m.: 20131204-IR- 405130422FRA; readopted filed Nov 13, 2019, 11:54 a.m.: 20191211-IR-405190487RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)