1. (a) For all Medicaid admissions identified for review, the TMRP review process includes, but is not limited to, the following:

   1. (1) admission review, which is a determination of the medical necessity of the admission;
   2. (2) diagnosis-related group (DRG) validation, which consists of a determination that the critical elements necessary to assign a DRG are present in the medical record. Hospital staff are responsible and held accountable for the accuracy of the required critical elements. Those elements are age, sex, discharge status, principal diagnosis, principal procedures, and any complications or comorbidities. This process is also a determination 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, or increased nursing care and/or monitoring, or in case of a newborn, one which the physician deems to have clinically significant implications for future health care needs. Normal newborn conditions or routine procedures are not to be considered as complications or comorbidities for DRG assignment. 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 changed, added, or deleted. When it is determined that the diagnoses and procedures are substantiated and sequenced correctly, the information will be entered into the applicable version of the Grouper software for a DRG determination. The Health Care Financing Administration (HCFA) approved DRG Grouper software considers each diagnosis and procedure and the combination of all codes and makes a determination of the final DRG assignment;
   3. (3) quality of care review, which is an assessment of the quality of care provided to determine if it 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;
   4. (4) readmission review, which consists of reviewing each admission on its individual merits as well as determining if the second or subsequent admissions were the direct result of a premature discharge or to provide services that should have been provided in the first admission;
   5. (5) day outlier review, which consists of verifying the medical necessity of each day of the admission;
   6. (6) cost outlier review, which consists of verifying that services billed were medically necessary, ordered by a physician, rendered and billed appropriately, and substantiated in the medical record; and
   7. (7) emergency service review, which consists of verifying that the emergency principal diagnosis (billed and paid), is substantiated in the medical record. If the admission is to a noncontracted hospital in the Medicaid Selective Contracting Program or any other hospital approved for emergency inpatient services only and the process of normal DRG validation, as stated in paragraph (2) of this subsection, results in a change to the principal diagnosis that consequently designates the admission as nonemergency, all monies paid shall be recouped by the Texas Department of Health (department) or its contractor.
2. (b) The department or its contractor shall review the complete medical record to make decisions on all aspects of the review process including but not limited to the medical necessity of the admission, DRG validation, and quality of care. The complete medical record must include but is not limited to: medical/surgical history and physical examination, discharge summary, physicians' progress notes, physicians' orders, lab reports, x-ray reports, operative reports, pathology reports, nurses' notes, medication sheets, vital signs sheets, therapy notes, specialty consultation reports, and special diagnostic and treatment records. If the complete medical record is not available or is not made available during the review, a preliminary technical denial is issued and the facility is notified.
3. (c) A practicing physician consultant shall make all decisions regarding any aspect of the review process that involves determining medical necessity, cause of readmission, or appropriateness of setting regarding the service provided. In the event the practicing physician consultant determines the services were not medically necessary, should have been provided in the first admission, or were not provided in the appropriate setting, the hospital shall be notified in writing of that decision, and the appropriate action shall be taken.

Source Note:The provisions of this §371.203 adopted to be effective July 11, 1989, 14 TexReg 3060; amended to be effective February 1, 1991, 16 TexReg 232; amended to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective July 27, 1994, 19 TexReg 5493; amended to be effective November 22, 1995, 20 TexReg 9274; amended to be effective March 25, 1996, 21 TexReg 2079; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308.