1. (a) The TMRP review process includes, but is not limited to:

   1. (1) Admission review to evaluate the medical necessity of the admission. For purposes of the TMRP, Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select II Contract reviews, medical necessity means the patient has a condition requiring treatment that can be safely provided only in the inpatient setting.
   2. (2) Diagnosis related group (DRG) validation to confirm 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, admission date, discharge date, principal diagnosis, principal and secondary procedures, and any complications or comorbidities (secondary diagnoses). This process also determines 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, increased nursing care and/or monitoring, or in the case of a newborn, conditions the physician deems to have clinically significant implications for future health care needs. 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 deleted, changed, or added. When the correct diagnosis and procedure coding and sequencing have been determined, the information will be entered into the applicable version of the Grouper software for a DRG assignment. The Centers For Medicare and Medicaid Services (CMS) approved DRG Grouper software considers the required critical elements and determines the final DRG assignment. If the DRG validation process results in deletions, changes, or additions to the critical elements, and these changes cause the DRG to be reassigned, the Texas Health and Human Services Commission (Commission) will direct the claims administrator to adjust the payment to the hospital accordingly.
   3. (3) Quality of care review to assess whether the quality of care provided 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. If quality of care issues are identified, physician consultants under contract with the Commission, and of the specialty related to the care provided, will determine possible clinical recommendations or corrective actions.
   4. (4) Readmission review to evaluate each admission on its individual merits and determine if the second or subsequent admissions resulted from a premature discharge or were required to provide services that should have been provided in a previous admission.
   5. (5) Day outlier review to verify the medical necessity of each day of the admission and includes DRG validation.
   6. (6) Cost outlier review to verify that services billed were medically necessary, ordered by a physician, rendered and billed appropriately, and substantiated in the medical record.
2. (b) The Commission will review the complete medical record for the requested admission(s) to make decisions on all aspects of this review process. The complete medical record may include: emergency room records, 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 during the review, the Commission will issue a preliminary technical denial and notify the facility.
3. (c) A physician consultant under contract with the Commission will make all decisions concerning medical necessity, cause of readmission, and appropriateness of setting for the service provided. In the event the physician consultant determines the services were not medically necessary, should have been provided in a previous admission, or were not provided in the appropriate setting, the claim will be denied, and the Commission will notify the hospital in writing. If a hospital claim is denied for lack of medical necessity or for being provided in an inappropriate setting, the Commission will consider for denial physician claims associated with the hospital admission or service when such claims can be identified and are deemed to be the result of inappropriate admission orders.

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; amended tobe effective March 30, 2003, 28 TexReg 2481; amended to be effective January 11, 2004, 29 TexReg 357.