PURPOSE: This rule establishes a limitation on admissions occurring on Friday or Saturday for inpatient hospital care and on the number of days of preoperative inpatient hospital care which may be paid for by Title XIX Medicaid on behalf of eligible recipients. Budgetary limitations necessitate the restriction.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to 13 CSR 70-15

exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

1. (1) For inpatient hospital admissions that have been certified under 13 CSR 70-15.020 and for admissions that do not require certification, the number of days which Medicaid will cover for each admission and continuous period of hospitalization shall be limited to the lowest of subsection (1)(A), (B) or (C). General Relief (GR) recipients are further limited in section (7) of this rule.

   1. (A) The number of days indicated as appropriate in accordance with the length-ofstay schedule as set forth in paragraph (1)(A)1. with the exception of those specific diagnoses for which a length-of-stay schedule has been developed by the Medicaid agency as set forth in paragraphs (1)(A)2. and 3., or as stated in paragraph (1)(A)4., or as established in 13 CSR 70-15.020 and as stated in paragraph (1)(A)5.

      1. 1. For the diagnosis at the 75th per-

centile average length-of-stay in the 1988 edition of the Length of Stay by Diagnosis for the United States, North Central Region for claims and adjustments processed for payment on or after January 1, 1990.

1. 2. A length-of-stay schedule, as devel-

oped by the Medicaid agency, for limited categories of rehabilitation diagnoses provided in facilities which meet the following criteria:

1. A. Medicare certification of ten (10)

beds or more as a rehabilitation hospital or a rehabilitation distinct part which is exempt from the Medicare prospective rate-setting system; or

1. B. Certification of ten (10) beds or

more by the Commission for Accreditation of Rehabilitation Facilities.

Diagnosis Description, Code and Days Spinal cord injury—quadriplegia—Code SC1—thirty (30) days Spinal cord injury—cervical fracture—Code SC2—twenty-five (25) days Spinal cord injury—paraplegia—Code SC3— thirty (30) days Spinal cord injury—hemiplegia—Code SC4— twenty-five (25) days Cerebral vascular accident—Code CVA— twenty-nine (29) days Head trauma—Code HT1—thirty-five (35) days Muscular dystrophy—Code MUD—twenty

1. (20) days Orthopedic trauma—arm—Code OT1— twenty-nine (29) days Orthopedic trauma—leg—Code OT2—twenty-nine (29) days Late effect of injury to the nervous system— Code ENS—thirty (30) days Degenerative joint disease—Code DJD— twenty (20) days.

   1. 3. An average length-of-stay schedule,

as developed by the Medicaid agency, for liveborn infants according to type of birth.

Diagnosis Description, Code and Days

V3000, V3900 Single diagnosis, not operated—three (3) days Single diagnosis, operated—four (4) days Multiple diagnosis, not operated—four (4) days Multiple diagnosis, operated—ten (10) days V3001, V3101, V3201, V3301, V3401, V3501, V3601, V3701, V3901 Single diagnosis, not operated—three (3) days Single diagnosis, operated—three (3) days Multiple diagnosis, not operated—five (5) days Multiple diagnosis, operated—fifteen (15) days V3100, V3200, V3300, V3400, V3500, V3600, V3700 Single diagnosis, not operated—four (4) days Single diagnosis, operated—four (4) days Multiple diagnosis, not operated—seven

1. (7) days Multiple diagnosis, operated—twelve (12) days

V301, V311, V321, V331, V341, V351, V361, V371, V391 Single diagnosis, not operated—two (2) days Single diagnosis, operated—two (2) days Multiple diagnosis, not operated—four (4) days Multiple diagnosis, operated—fifteen (15) days

Any liveborn low birthweight (under two thousand grams (2,000 g)) born in a hospital or before admission to a hospital, single or multiple diagnosis, operated or not operated, may be billed under the code GRO. All inpatient days to and including the day on which the infant reaches two thousand grams (2,000 g) weight will be paid. Use of this code will require attachment to the claim of medical chart progress notes which show the date on which this weight is attained.

1. 4. For infants who are less than one (1)

year of age at admission, all medically necessary days will be paid at any hospital. For children who are less than six (6) years of age at admission and who receive services from a disproportionate share hospital, all medically necessary days will be paid.

1. 5. Continued stay reviews will be per-

formed for alcohol and drug abuse detoxification services to determine the days that are medically necessary and appropriate for inpatient hospital care.

1. (B) The number of days certified as medically necessary by the Hospital Utilization Review Committee.
2. (C) The number of days billed as covered service by the provider.

1. (2) In administering this limitation, the counting of days which may be allowable under the provider’s internal Hospital Utilization Review Committee’s certified medically necessary days always shall be from the beginning date of admission for a continuous period of hospitalization. The counting of days which may be Medicaid allowable also will be from the beginning date of admission unless conditions described in subsection (2)(A), (B) or (C) apply.

   1. (A) If the recipient’s beginning date of eligibility is later than the date of admission, the counting of days which may be allowable will be from the beginning eligibility date.
   2. (B) If the recipient has exhausted Title XVIII inpatient benefits, the counting of days which may be allowable will be from the date following the date on which the Title XVIII benefits are exhausted.
   3. (C) If the date of admission is not certified under 13 CSR 70-15.020 as medically necessary, the counting of days which may be allowable for reimbursement will be from the date approved for admission by the medical review agent.
2. (3) Except for reimbursement rates applicable to GR recipients, inpatient services as described in section (6) of this rule, reimbursement shall be made at the applicable per diem rate in effect as of the initial date of admission and for only allowable days during which the recipient is eligible.
3. (4) This limitation applies to inpatient hospital stays or portions of hospital stays during which there are no Medicare Part A Benefits available.
4. (5) Effective with this limitation, there shall be no provision for claiming of additional covered days through submission of a form of medical necessity and medical documentation.

5. (6) Effective for all inpatient hospital admissions of GR assistance recipients on or after September 1, 1981, Medicaid payment for covered services provided during the allowable days of each admission shall be made at the lesser of—

   1. (A) The rate which was in effect

between the hospital and the Medicaid program on September 1, 1981; or

1. (B) The rate which was in effect

between the hospital and the Medicaid program as of the beginning date of the hospital admission.

1. (7) Effective for inpatient hospital stays for GR assistance recipients beginning on or after January 1, 1982, Medicaid coverage of the number of days during any one (1) continuous period of hospitalization will be limited to a maximum of twenty-one (21) days during which the recipient is Medicaid-eligible and if twenty-one (21) days should be the lesser of allowable days as derived from provisions of sections (1) and (2).

2. (8) Exception Process.

   1. (A) An exception process to the coverage of inpatient days as determined under provisions of section (1) shall be established for post-payment consideration of inpatient claims exceeding fifteen (15) days beyond the allowable days, if requested by the provider, and the date of receipt was prior to September 1, 1986.
   2. (B) For requests received on or after September 1, 1986, for admissions prior to July 1, 1988, post-payment consideration of inpatient claims will only be made for claims exceeding thirty (30) days beyond the allowed days. Only the days exceeding thirty (30) days beyond the allowed days are eligible for approval; days one through thirty (1–30) in excess of the allowed days are not eligible for consideration of approval nor additional reimbursement. There will be no post-payment consideration of inpatient claims for admissions on and after July 1, 1988.
   3. (C) The state agency will conduct reviews, approve and specify any additional days which may be allowed beyond the number of days already paid, or may review recommendations submitted by either a duly appointed Medicaid utilization review subcommittee or a medical consultant licensed to practice medicine in Missouri. At its discretion, the state may concur with a recommendation and approve all days for payment, disagree and not pay any days or modify and pay some portion of the days recommended.
   4. (D) Reimbursement for any additional days approved for acute care will be made at the hospital’s per diem rate in effect on the date of admission. If a hospital has an established intermediate care facility/skilled nursing facility (ICF/SNF) or SNF-only Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for any additional days approved for only ICF or SNF level of care provided in the inpatient hospital setting will be made at the hospital’s ICF/SNF or SNF-only rate. If a hospital does not have an established ICF/SNF or SNF- only Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for any additional days approved for only ICF or SNF level of care will be made at the statewide swing bed rate. No additional days will be approved and no Medicaid payments will be made on behalf of any recipient who it is determined received inpatient hospital care when s/he did not need either inpatient hospital services or nursing home ICF or SNF services.
   5. (E) Requests for post-payment consideration of inpatient claims must be received no later than one (1) year from the date of discharge.

AUTHORITY: sections 208.153, RSMo Supp. 1991 and 208.201, RSMo Supp. 1987.* This rule was previously filed as 13 CSR 40- 81.051. Emergency rule filed April 7, 1981, effective April 20, 1981, expired July 10, 1981. Original rule filed April 7, 1981, effective July 11, 1981. Emergency amendment filed July 15, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Emergency amendment filed Aug. 21, 1981, effective Sept. 1, 1981, expired Dec. 10, 1981. Amended: Filed July 15, 1981, effective Oct. 11, 1981. Emergency amendment filed Nov. 20, 1981, effective Dec. 1, 1981, expired March 10, 1982. Amended: Filed Aug. 21, 1981, effective Dec. 11, 1981. Amended: Filed Nov. 20, 1981, effective March 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Nov. 24, 1982, effective Dec. 4, 1982, expired March 10, 1983. Amended: Filed Nov. 24, 1982, effective March 11, 1983. Emergency amendment filed April 8, 1983, effective April 18, 1983, expired July 10, 1983. Amended: Filed April 8, 1983, effective July 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective March 28, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984. Amended: Filed Oct. 15, 1984, effective Feb. 11, 1985. Amended: Filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed April 2, 1986, effective Sept. 1, 1986. Amended: Filed June 17, 1986, effective Sept. 1, 1986. Emergency amendment filed Sept. 17, 1986, effective Sept. 27, 1986, expired Jan. 25, 1987. Amended: Filed Aug. 1, 1986, effective Oct. 11, 1986. Amended: Filed Nov. 14, 1986, effective Jan. 30, 1987. Amended: Filed May 4, 1987, effective July 23, 1987. Amended: Filed Jan. 5, 1988, effective March 25, 1988. Amended: Filed April 4, 1988, effective July 1, 1988. Emergency amendment filed Dec. 1, 1989, effective Jan. 1, 1990, expired April 29, 1990. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Amended: Filed Dec. 4, 1989, effective Feb. 25, 1990. Emergency amendment filed June 18, 1991, effective July 15, 1991, expired Oct. 28, 1991. Amended: Filed March 18, 1991, effective Aug. 30, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Amended: Filed June 18, 1991, effective Oct. 31, 1991. Amended: Filed June 18, 1991, effective Oct. 31, 1991. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1991 and 208.201, RSMo 1987.