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KANSAS
MEDICAL
ASSISTANCE
PROGRAM
PROVIDER MANUAL
Hospital
PART II
HOSPITAL PROVIDER MANUAL
Introduction
Section
7000
7010
7020
7030
8100
8200
8300
8400
8410
8420
8430
BILLING INSTRUCTIONS
UB-04 Billing Instructions .... .........
Submission of Claim . .........
MS-2126 Billing Instructions . .........
Hospital Specific Billing Information .
State Institution for Mental Health
Billing Instructions .... .........
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7-8
7-9
7-13
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7-22
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8-1
8-2
8-15
8-16
8-27
8-32
8-36
Appendix I
Codes ......... ........ ......... ......... ......... ......... ......... ........
AI-1
Appendix II
Hospital Cost Report .. ......... ......... ......... ......... ......... ........
AII-1
BENEFITS AND LIMITATIONS
Copayment .... ........ ......... .........
Medical Assessment .. ......... .........
Benefit Plans .. ........ ......... .........
Medicaid ....... ........ ......... .........
Medicaid-Inpatient Only ....... .........
Medicaid-Outpatient Only ..... .........
Family Planning/Sterilization . .........
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DRG Weights and Rates
FORMS
All forms pertaining to this provider manual can be found on the public website at
https://www.kmap-state-ks.us/Public/forms.asp and on the secure website at
https://www.kmap-state-ks.us/provider/security/logon.asp.
CPT codes, descriptors, and other data only are copyright 2009 American Medical Association (or such other date of
publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information on the American Medical
Association is available at http://www.ama-assn.org.
PART II
HOSPITAL PROVIDER MANUAL
Updated 10/09
This is the provider specific section of the manual. This section (Part II) was designed to provide
information and instructions specific to hospital providers. It is divided into three subsections: Billing
Instructions, Benefits and Limitations, and Appendices.
The Billing Instructions subsection provides directions on how to complete and submit gives
examples of the billing forms applicable to hospital services. The forms are followed by directions for
completing and submitting them.
The Benefits and Limitations subsection defines specific aspects of the scope of hospital services
allowed within the KHPA Medical Plans.
The Appendix subsection contains information concerning procedure codes and the hospital cost
report., emergency diagnosis codes and swing bed nursing facility supplies. The appendices were
developed to make finding and using codes easier for the biller.
HIPAA Compliance
As a KMAP participant, pProviders are required to comply with compliance reviews and complaint
investigations conducted by the Secretary of the Department of Health and Human Services as part of
the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the
code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and
Human Services all information required by the department during its review and investigation. The
provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse
Division of the Kansas Attorney General's Office upon request from such office as required by
K.S.A. 21-3853 and amendments thereto.
A provider who receives such a request for access to or inspection of documents and records must
promptly and reasonably comply with access to the records and facility at reasonable times and
places. A provider must not obstruct any audit, review or investigation, including the relevant
questioning of employees of the provider. The provider shall not charge a fee for retrieving and
copying documents and records related to compliance reviews and complaint investigations.
7000. HOSPITAL BILLING INSTRUCTIONS Updated 10/09
Introduction to the UB-04 Claim Form
Hospital providers must use the UB-04 red claim form when requesting payment for medical services
and supplies provided under the KHPA Medical Plans. Any UB-04 claim not submitted on the red
claim from will be returned to the provider. An example of the UB-04 claim form is on both the
public and secure websites (see the Table of Contents for hyperlinks) in the Forms section at the end
of this manual. Instructions for completing this claim form are included in the following pages. The
Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment.
Therefore, information will not be recognized if not submitted in the correct fields as instructed.
The fiscal agent does not furnish the UB-04 claim form to providers. Refer to Section 1100 of the
General Introduction Provider Manual.
The following numbered form locators (FL) are to be completed when required or if applicable.
Completing the UB-04 claim form:
FL 1
Billing Provider Name, Address and Telephone Number – Required. Enter
the name and address of the billing provider.
FL 3A
Patient Control No. Enter a patient account number if desired. (This number
will be referenced on the Remittance Advice [RA].)
FL 3B
Medical Record No.-Desired. Enter the patient’s medical record number.
(This number will appear on the provider’s RA.)
FL 4
Type of Bill - Required. Enter the three-digit number specific to the type of
claim.
1st digit indicates facility.
2nd digit indicates location within facility.
3rd digit indicates the frequency of the claim billed.
Medicaid allowed codes:
1st digit:
1 Hospital (IP/OP)
8 Outpatient – Critical Access
2nd digit:
1 Inpatient
3 Outpatient
5 Critical Access Hospital
8 Swing bed NF
3rd digit:
0 Nonpayment/zero claim
1 Admit through discharge claim
2 Interim - first claim
3 Interim - continuing claim
4 Interim - last claim (thru date is discharge date)
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-1
7000. Updated 12/08
FL 5
Federal Tax Number – Required.
FL 6
Statement Covers Period – From/Through – Required. Enter inpatient
dates of admission and discharge or outpatient from and through dates in
MM/DD/YY format.
FL 7
Reserved for assignment by NUBC. Covered Days - Required - Inpatient
Only. Enter the number of days for which you are billing.
Note: Count date of admission, but not date of discharge.
FL 8
Patient Name/Identifier – Required. Enter patient's last name, first name
and middle initial exactly as it appears on the ID card. If patient is a newborn,
enter "newborn", "baby boy", or "baby girl" in the first name field and enter
the last name.
FL 9
Patient Address – Required.
FL 10
Birthdate – Required. Enter patient's date of birth in MM/DD/YYYY
format. If newborn, enter baby's date of birth (not mother's).
FL 11
Sex – Required. Enter "M" for male or "F" for female. If newborn services,
enter "M" or "F" for the baby.
FL 12
Admission/Start of Care Date – Required. Enter date patient was admitted
as inpatient or date of outpatient care in MM/DD/YY format.
FL 13
Admission Hour – Required – Inpatient Only. Enter treatment hour using
the continental time system (i.e., 6:00 p.m. equals 1800 hours).
FL 14
Priority Type of Visit Admission Type–Required – Inpatient Only. Enter a
one-digit code to indicate type of admission.
1 – Emergency
3 – Elective
5 – Trauma
2 – Urgent, etc.
4 – Newborn
FL 15
Point of Origin for Admission or Visit Admission Source– Required.
Enter a one-digit code to indicate admission source.
1 – Nonhealth care facility point of origin
2 – Clinic
3 – Reserved for assignment by NUBC
4 – Transfer from hospital
5 – Transfer from skilled nursing facility Nursing Home
6 – Transfer from another healthcare facility
7 – Emergency room
8 – Court/law enforcement
9 – Information not available
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-2
7000. Updated 09/09
A – Reserved for assignment by NUBC
B – Transfer from another home health facility
C – Readmission to same home health agency
D – Transfer from one distinct unit of the hospital to another distinct
unit of the same hospital resulting in separate claim to the payer
E – Transfer from ambulatory surgery center
F – Transfer from hospice and is under a hospice plan of care or
enrolled in a hospice program
G-Z – Reserved for assignment by NUBC
Code structure for newborn
1-4 – Reserved
5 – Born inside this hospital
6 – Born outside of this hospital
7-9 – Reserved
FL 16
Discharge Hour – Required on inpatient claims with a frequency code of
1 or 4 except Type of Bill 021X.
FL 17
Patient Status - Required - Inpatient Only. Enter a two-digit code to
indicate status of patient:
01
Discharged to home or self care (routine discharge)
02
Discharged/transferred to another short-term general hospital for
inpatient care
03
Discharged/transferred to skilled nursing facility (SNF) with Medicare
certification
04
Discharged/transferred to a facility that provides custodial or
supportive care an Intermediate Care Facility (ICF)
05
Discharge/transfer to a designated cancer center or children’s hospital
06
Discharged/transferred to a home under care of organized home health
service organization
07
Left against medical advice or discontinued care
08
Discharged/transferred to home under care of a home IV drug therapy
provider (This is not a certified Medicare provider.)
09
Admitted as an inpatient to this hospital (for use on Medicare
Outpatient Hospital claims only)
20
Expired (or did not recover - Christian Science Patient)
21
Discharged/transferred to court/law enforcement
30
Still patient
40
Expired at home (Hospice claims only)
41
Expired in a medical facility, such as a hospital, SNF, ICF, or
freestanding hospice (Hospice claims only)
42
Expired - place unknown (Hospice claims only)
43
Discharge/transferred to a Federal Health Care Facility
50
Discharge to hospice – home
51
Discharge to hospice - medical facility
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-3
7000. Updated 09/09
61
62
63
64
65
66
70
Discharged/transferred within this institution to a hospital-based,
Medicare-approved, swing bed
Discharged/transferred to another rehabilitation facility an inpatient
rehabilitation facility (IRF) including rehabilitation distinct part units
of a hospital
Discharged/transferred to a Medicare certified long term care hospital
(LTCH)
Discharged/transferred to a nursing facility certified under Medicaid
but not certified under Medicare
Discharged/transferred to a psychiatric hospital or psychiatric distinct
part unit of a hospital
Discharged/transferred to a Critical Access Hospital (CAH) for
discharge dates on or after January 1, 2006
Discharged/transferred to another type of health care institution not
defined elsewhere in the code list
Note: Hospitals will be eligible for full DRG reimbursement when a discharge
occurs using discharge code 01, 03, 04, 05, 06, 07, 08, 20, 50, or 51.
Distinct claim forms must be submitted for each discharge. In the case of
transfers to same specialty providers (discharge code 02), the transferring
hospital’s reimbursement may be reduced, based upon a transfer prorated
reimbursement determination, and the receiving hospital will be eligible to
receive a full DRG reimbursement.
FL 18-28
Condition Codes – Enter one of these two-digit codes to indicate a
condition(s) relating to inpatient or outpatient claims, special programs or
procedures (e.g., KAN Be Healthy, sterilization)
Note: This is not a complete list. For a complete list of Condition Codes
contact Customer Service.
01 Military service related
02 Condition is employment related
03 Patient covered by insurance not reflected here
67 Beneficiary elects not to use life time reserve (LTR) days
Note: This will now replace the Z1 Medicare Part A benefits exhausted
condition code. The verbiage in the explanation of condition code 67
means the patient’s benefits are exhausted.
80 Home Dialysis – Nursing Facility
A1 KAN Be Healthy (EPSDT)
A4 Family Planning
AA Abortion performed due to rape
AB Abortion performed due to incest
AI Sterilization
D9 Any other change
Note: This will now replace the XO swing bed condition code.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-4
7000. Updated 12/08
FL 31-34
Occurrence Codes/Dates: OCCURRENCE CODES CAN ONLY BE
SUBMITTED ON LINE A.
The following occurrence codes must be indicated if reporting information on
type of accident, crime victim, other insurance denial or date of TPR
termination, or aborted surgery, false labor or nondelivery claim where
associated services are indicated.
01
Accident/medical coverage
02
No fault insurance involved – including auto accident/other
03
Accident/tort liability
04
Accident/employment related
05
Accident/no medical or liability coverage
06
Crime victim
24
Date insurance denied
25
Date benefits terminated by primary payer
A3
Benefits exhausted, Payer A
B3
Benefits exhausted, Payer B
C3
Benefits exhausted, Payer C
All State of Kansas Department of Social and Rehabilitation Services (SRS)
guidelines remain the same regarding attachments required for TPR proof and
SSA/Medicare EOMBs.
FL 35-36
Occurrence span codes and dates.
FL 37
Reserved for assignment by NUBC.
FL 38
Responsible party name and address (claim addressee) – situational.
FL 39-41
Value Codes/Amount – Required if applicable.
• Enter D3 for nonpatient obligation as the value code. Enter the
nonpatient obligation dollar amount in the “Amount” field. Examples of
nonpatient obligation are Parental, Spousal, and Trust.
• Enter 80 for covered days and enter the number of covered days in the
Amount field.
Note: Count the date of admission but not the date of discharge.
FL 42
Revenue Code – Required – Inpatient Only. Enter the three-digit number
identifying the type of accommodation and ancillary service(s). DO NOT
INDICATE REVENUE CODE(S) IF THE SERVICE IS NONCOVERED.
Note: Revenue codes are not to be indicated for outpatient services.
FL 43
Revenue Description/IDE Number/Medicaid Drug Rebate – Required on
paper bills only.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-5
7000. Updated 12/08
FL 44
HCPCS/Accommodation Rates/HIPPS Rates Code – Required –
Outpatient Only. List the HCPCS procedure code for each specific
outpatient procedure. DO NOT INDICATE PROCEDURE(S) IF THE
SERVICE IS NONCOVERED.
FL 45
Serv. Date – Required – Outpatient Only. Enter the date services were
provided in MM/DD/YY format.
FL 46
Serv. Units – Required. Enter number of days for each accommodation
revenue code or appropriate units for each outpatient service billed.
FL 47
Total Charges – Required. Enter total charges for each coded line item.
List each outpatient procedure with a specific (itemized) charge. DO NOT
INDICATE CHARGES FOR NONCOVERED SERVICES.
Enter the total claim charge on the last line of this detail section with a
revenue code of 001 in FL 42 and total charges in FL 47.
FL 48
Noncovered Charges – Situational Optional. Enter noncovered charges.
FL 49
Reserved.
FL 50
Payer Name – Required. Indicate all third party resources (TPR). If TPR
does exist, it must be billed first. Lines B and C should indicate secondary
and tertiary coverage. Medicaid will be either the secondary or tertiary
coverage and the last payer. When B and C are completed, the remainder of
this line must be completed as well as FL 58-62. Medicare needs to always be
the last entry.
FL 51
Health Plan Identification Number.
• Line A – Required
• Line B & C – Situational
FL 52
Release of Information Certification Locator – Required.
FL 53
Assignment of Benefits Certification Indicator – Required.
FL 54
Prior Payments Payer – Required if other insurance is involved. Enter
amount paid by other insurance. Medicare needs to always be the last entry.
(Do not enter spenddown or copayment amounts. These reductions will be
made automatically during claim processing.)
FL 55
Estimated Amount Due Payer – Situational.
FL 56
NPI. Enter the billing provider’s NPI.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-6
7000. Updated 12/08
FL 57
Other Provider ID: Enter either qualifier ‘1D’ and the billing provider’s
KMAP provider ID or qualifier ‘ZZ’ and the taxonomy code.
FL 58
Insured’s Name – Required.
FL 59
Patient’s Relationship to Insured.
• Line A – Required
• Line B & C – Situational
FL 60
Insured’s Unique ID – Required. Enter the 11-digit beneficiary number from
patient's medical ID card on line C. If newborn services, use mother's
beneficiary number if newborn's ID number is unknown.
FL 61-62
Insured’s Group Name/Insurance Group No. – Required if group name is
available and FL 62 is not used Medicaid is not primary payer. Enter the
primary insurance information on line A and Medicare on line C.
FL 62
Insured’s Group Number – Required when insured’s identification card
shows a group number.
FL 63
Treatment Authorization Codes - Leave blank. (This number, if applicable,
is system generated.)
FL 64
Document Control Number – Required when TOB code (FL 04) indicates
this claim is a replacement or void to a previously adjudicated claim.
Desired if this claim is a resubmission. Enter the previous ICN.
Note: This field is for timely filing purposes.
FL 65
Employer Name (of the Insured) – Situational.
FL 66
Diagnosis and Procedure Code Qualifier – Qualifier code 9 required.
FL 67
Principal Diagnosis Code and Present on Admission Indicator – Principal
Diagnosis Code – Required. Present on Admission Indicator – Required.
Follow the official coding guidelines for ICD reporting.
FL 67A-Q
Other Diagnoses Codes and Present on Admission Indicator – Required
when other conditions coexist or develop during the patient’s treatment.
Present on Admission Indicator – Required when other diagnoses included.
DX - Required. Enter the ICD-9-CM code indicating the primary diagnosis
and additional diagnoses.
FL 68
Reserved for Assignment by the NUBC.
FL 69
Admitting Diagnosis Code – Required when claim involves an inpatient
admission.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-7
7000. Updated 12/08
FL 71
Prospective Payment System (PPS) Code.
FL 72A-C
External Cause of Injury (ECI) Code and Present on Admission
Indicator – Required when an injury, poisoning or adverse affect is cause
for seeking medical treatment or occurs during medical treatment. Present
on Admission Indicator – Required for UB04. See FL 67.
FL 74
Principal Procedure Code and Date – Required on inpatient claims Inpatient/Outpatient, if applicable. Enter the ICD-9-CM procedure code for
the primary procedure and date of service. DO NOT INDICATE THE
PROCEDURE IF THE SERVICE IS NONCOVERED.
FL 74A-E
Other Procedure Codes and Dates – Required – Inpatient/Outpatient, if
applicable. Enter other procedures performed, using ICD-9-CM procedure
codes and date of service. DO NOT INDICATE THE PROCEDURE IF
THE SERVICE IS NONCOVERED.
FL 76
Attending Provider Name and Identifiers – Required.
a. Enter attending physician's NPI, or the appropriate qualifier and
physician’s KMAP provider ID or taxonomy code.
b. Enter attending physician's Medicaid provider name as last name and then
first name.
Note: DO NOT ENTER A GROUP PROVIDER NUMBER.
FL 77
Operating Physician Name and Identifiers – Required if applicable.
a. Enter operating physician's NPI, or the appropriate qualifier and
physician’s KMAP provider ID or taxonomy code.
b. Enter operating physician's Medicaid provider name as last name and then
first name.
FL 78-79
Other Provider (Individual) Names and Identifiers - Required if
applicable.
a. Enter other physician's NPI or the appropriate qualifier and physician’s
KMAP provider ID or taxonomy code.
b. Enter other physician's Medicaid provider name as last name and then first
name.
Note: If the claim is for a sterilization, the surgeon performing the sterilization procedure
must be identified by their KMAP provider ID in field 78.
FL 80
Remarks Field – Specify additional information as necessary.
Submission of Claim:
Send completed claim to:
Kansas Medical Assistance Program
Office of the Fiscal Agent
P.O. Box 3571
Topeka, Kansas 66601-3571
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-8
7010.
MS-2126 BILLING INSTRUCTIONS Updated 5/07
Introduction to the Notification of Nursing Facility Admission/Discharge MS-2126
The completion of the MS-2126 (Notification of Nursing Facility Admission/Discharge) shall
be completed by the provider and a copy sent to the local SRS office Economic &
Employment Specialist (EES). Submission of the MS-2126 is not required as a prerequisite
for a hospital "reserve day" (Section IV). However, the MS-2126 must be retained in the
beneficiary's file for documentation. Completion of the MS-2126 is not required for payment
of a therapeutic reserve day.
This form will need to be copied or duplicated by providers since neither the fiscal agent nor
the state will furnish the form to providers.
When to Use the MS-2126:
Sections I, II, and III, "Facility Placement/Discharge" shall be initiated by the nursing
facility when:
1.
2.
3.
4.
5.
6.
An eligible Kansas Medical Assistance Program resident is initially admitted to or
discharged from the nursing facility (NF), nursing facility for mental health (NF/MH)
or intermediate care facility for the mentally retarded (ICF/MR).
A resident of an NF, NF/MH, or ICF/MR becomes eligible for Kansas Medical
Assistance Program.
An eligible Kansas Medical Assistance Program resident transfers from one facility to
another facility.
A resident's eligibility has been reinstated after suspension for more than two months.
(If two calendar months or less, a new form will be needed.)
An eligible Kansas Medical Assistance Program resident is out of the facility for more
than 30 days. (This is the same as a new admission.) When a resident returns to the
facility on the 31st day, a new form will not be required. When a resident fails to
return on the 31st day, a new form is required.
An eligible Kansas Medical Assistance Program resident has a change in his/her level
of care.
Section IV, Hospital Leave Information shall be initiated by the facility to report any hospital
admission and to report reserve days for a medical leave being claimed by the facility.
Completion of this section is not required for therapeutic (home) leave days.
When a single hospital stay exceeds 30 days, the facility shall send another form to the local
SRS office indicating the stay has exceeded 30 days and listing the estimated number of days
the beneficiary will remain in the hospital.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-9
7010. Updated 5/07
Return to the Facility:
Whether Section III or IV is being completed, the EES retains a copy of this form for their
files. The original MS-2126, completed by the facility, and the Notice of Action must be
retained by the nursing facility.
How to Complete the MS-2126:
Section I:
Name: Enter the resident's first name, middle initial, and last name as it appears on the
medical identification (ID) card.
SSN: Enter the resident's Social Security number. If the resident does not have a Social
Security number, enter "NA."
Date of Birth: Enter the resident's birth date in month, day, and year - MM/DD/YYYY
format. (Example: May 15, 1925 should appear as 05-15-1925.)
Sex: Indicate "M" for male and "F" for female.
Client ID Number: Enter the 11-digit resident number from the individual's Kansas Medical
Assistance Program card.
Responsible Person's Name: Enter the first and last name of the responsible party.
Responsible Person's Address: Enter the responsible person's street address, P.O. Box
number, along with his/her city, state, and zip code.
Phone: Enter the responsible party's area code and phone number.
Section II:
Facility Name: Enter the name under which the facility operates.
Provider Number: Enter your 10-digit Medicaid provider number.
Address: Enter the street address, city, and zip code where the facility is located.
KANSAS MEDICAL ASSISTANCE PROGRAM
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7-10
7010. Updated 5/07
Date of Placement: Date resident was admitted to the facility.
Anticipated Length of Stay: Enter the number of months the resident is expected to be in
the facility. If unknown, write "unknown."
Screened By: Enter the name of the person or facility completing the assessment. The State
of Kansas requires that "each individual prior to admission to an NF .... receive assessment
and referral services." To achieve this, the CARE program was created "for the data
collection and individual assessment and referral to community-based services and appropriate
placement in long-term care facilities.
Date: Date screening was completed (if known).
Signature: The facility administrator or his/her designee signs here.
Phone: In the event there are questions, please indicate the area code and telephone number
to call.
Section III: Enter a check mark in the appropriate space to indicate (A) Admission, (B) Discharge,
or (C) Deceased. Providers will also need to indicate the method of payment in place at the time of
admission or discharge.
A1.
Admitted From: Indicate where the resident is being admitted to and the name of the
facility they are coming from.
A2.
Indicate method of payment at time of admission.
B1.
Discharged On: Check the appropriate space to indicate where the resident is being
discharged to, name of facility, and date of discharge.
B2.
Indicate method of payment at time of discharge.
C.
Deceased Date: Enter the resident's date of death.
Section IV:
A.
Entered: Enter the name of the hospital and the date entered.
B.
Reason Admitted: If known, indicate reason for admission. If unknown, write
"UNKNOWN".
C.
Estimated Days in Hospital: Indicate the number of days the admitting physician
reasonably believes the resident will be in the hospital.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-11
7010. Updated 5/07
Reserve Day Notice - Once the facility has completed this form, it should be submitted to the local
SRS office. Since the information sent to the SRS office will not be returned, it is important for the
facility to keep the original in their files.
Nursing Facility Processes Form
III.
Facility Placement/Discharge: The facility is required to retain the completed form
in the facility. These records shall be made available to SRS and/or the fiscal agent upon
request. Suspension of payment to the facility may result in the absence of this form.
IV.
Hospital Leave Day Form: Retain the completed form in the beneficiary's records
for documentation of medical reserve day approval.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BILLING INSTRUCTIONS
7-12
7020. HOSPITAL SPECIFIC BILLING INFORMATION Updated 03/08
Inpatient
Accommodation and Ancillary Charges:
If the individual accommodation and ancillary services exceed the detail lines on the UB-04
claim form, providers may combine all similar revenue code charges together (e.g., lab,
radiology) when necessary. Accommodation codes may also be 'lumped' together when
necessary. This will not affect the reimbursement of the claim.
Admission and Readmission (Same Day):
Admission
An inpatient admission starts when the physician writes an order for an inpatient admission. It
is not considered inpatient until that order has been written. Documented verbal admission
orders are considered the same as written orders.
• Scenario #1: A patient is sent to the medical floor on September 23 at 11:00 p.m. The
physician writes an order to admit the patient on September 24 at 3:00 a.m. According to
KMAP, the inpatient admission starts on September 24 at 3:00 a.m.
• Scenario #2: A physician writes an order for a patient to be admitted inpatient on
September 23 at 11:00 p.m. The patient arrives on the medical floor on September 24 at
3:00 a.m. According to KMAP, the inpatient admission starts on September 23 at
11:00 p.m.
• Scenario #3: A physician contacts a hospital on September 23 at 11:00 p.m. about a direct
admission and gives a verbal order for admission once the patient arrives at the hospital.
The patient arrives at the hospital on September 24 at 3:00 a.m. According to KMAP, the
inpatient admission starts on September 24 at 3:00 a.m.
Readmission (Same Day)
When a patient is discharged or transferred from an inpatient hospital and is readmitted to the
same inpatient hospital on the same day for symptoms related to or for evaluation and
management of the prior stay’s medical condition, hospitals must adjust the original claim
generated by the original stay by combining the original and subsequent stay onto a
single claim.
When a patient is discharged or transferred from an inpatient hospital and is readmitted to the
same inpatient hospital on the same day for symptoms unrelated to and not for evaluation and
management of the prior stay’s medical condition, hospitals must bill for two separate stays
on two separate claims.
Emergency Renal Dialysis:
Inpatient emergency renal dialysis must be billed utilizing revenue code 809 in FL 42 of the
UB-04 claim form.
Interim Billing:
Interim billing is restricted to once every 180 days. Interim bills received more frequently
than 180 days will be denied. When interim billing, be sure to enter the appropriate 'Type of
Bill' code (e.g., 112, 113, 114). A 'Patient Status' code of 30 (still a patient) must be
indicated when 'Type of Bill' is 112 or 113.
Medicare B Services:
When Medicare B payment is made on an inpatient claim, indicate the amount paid as Prior
Payment in FL 54 on the UB-04 claim form.
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Newborn Services (When the Mother Is NOT in an MCO)
When billing for a newborn who does not have a beneficiary ID number, use "Newborn",
"Baby Girl", or "Baby Boy" in the first name field of patient name. Use the newborn's date
of birth and the mother's beneficiary ID number. The claim will suspend in the claims
processing system for up to 45 days pending the fiscal agent's receipt of the newborn's
beneficiary ID number from the KMAP eligibility system. If the newborn's beneficiary ID
number is received within the 45 days, the claim will be processed using that number. If the
newborn's beneficiary ID number is not received within the 45 days, the claim will complete
processing with the mother's beneficiary ID number.
Newborn Services (When the Mother Is in an MCO)
Notify the MCO that the mother is assigned to at the time of birth. The MCO will provide
further instructions if the provider is part of that MCO’s network. The mother's MCO will
notify Kansas Health Policy Authority (KHPA) and the fiscal agent of the birth.
Outpatient/Inpatient
Outpatient procedures (including, but not limited to, surgery, X-rays and EKGs) provided
within three days of a hospital admission for the same or similar diagnosis are considered
content of service and must be billed on the same inpatient hospital claim. The outpatient
procedure date should be changed on the claim to correspond with the actual hospital
admission date.
Note: There is one exception to this policy. Complications from an outpatient sterilization
resulting in an inpatient admission. In this instance, the outpatient charges and the inpatient
charges should be billed on two separate claims. This is necessary in order for the service
dates on the claim form to match the service dates on the Sterilization Consent Form.
Outpatient Services Provided During Inpatient Admission
Outpatient services provided during an inpatient hospital stay must be included by the hospital
on the UB-04 claim form and reimbursed through the DRG. The outpatient provider should
receive reimbursement from the hospital. Outpatient services provided to residents of state
institutions must be billed by the hospital providing the outpatient service.
Present on Admission (POA) Indicators
Effective October 1, 2008, all claims involving inpatient admissions to general acute care
hospitals will require submission of POA indicator(s). POA is defined as present at the time
the order for inpatient admission occurs – conditions that develop during an outpatient
encounter, including emergency department, observation, or outpatient surgery, are
considered as POA. Critical access hospitals, Maryland-waiver hospitals, long-term care
hospitals, cancer hospitals, and children’s inpatient facilities are exempt from this
requirement.
POA indicator is assigned to principal and secondary or other diagnoses (as defined in
Appendix I of the Official Coding Guidelines for Coding and Reporting) and the external
cause of injury codes. The validity of the POA indicator will be edited and claims are subject
to denying when the POA indicator is invalid. The hospital will need to supply the correct
POA indicator(s) and resubmit the claim.
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A POA indicator for the external cause of injury code is not required unless it is being
reported as an “other diagnosis” on the UB-04.
POA Indicators and Definitions
• Y (for yes): Present at the time of inpatient admission.
• N (for no): Not present at the time of inpatient admission.
• U (for unknown): The documentation is insufficient to determine if the condition was
present at the time of inpatient admission.
• W (for clinically undetermined): The provider is unable to clinically determine whether
the condition was present at the time of inpatient admission or not.
• 1 (for unreported/not used): Exempt from POA reporting.
Note: The ICD-9-CM Official Guidelines for Coding and Reporting includes a list of
diagnoses codes that are exempt from POA reporting. Use POA indicator 1 only for codes
on the list.
KMAP will not pay the complication comorbidity/major complication comorbidity (CC/MCC)
DRG for those selected hospital acquired conditions (HACs) that are coded as "U" for the
POA indicator. KMAP will not pay the CC/MCC for those selected HACs that are coded as
"1" for the POA indicator. The "1" POA indicator should not be applied to any codes on the
HAC list. These claims will deny as ungroupable, and providers will need to correct and
resubmit the claim for reimbursement. HAC information is available on the CMS website at:
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage
These POA guidelines are not intended to replace any found in the ICD-9-CM Official
Guidelines for Coding and Reporting nor are they intended to provide guidance on when a
condition should be coded. They should be used in conjunction with the UB-04 Data
Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to
facilitate the assignment of the POA indicator for each “principal” diagnosis and “other”
diagnoses codes reported on claim forms (UB-04 and 837 Institutional).
Psychiatric Observation Beds
When an inpatient hospital admission follows a psychiatric observation stay, the observation
days should be billed on the inpatient claim. The observation bed days then become part of
the DRG payment to the hospital.
Transfers
When billing medically necessary incoming transfers, in FL 80 on claims for incoming
transfers from other hospitals under "Remarks" enter "direct transfer from (hospital, city)".
Swing Bed Nursing Facility
When billing for a swing bed nursing facility (NF), the following must be observed:
1)
Your hospital must be certified by the Kansas Department of Health and Environment
(KDHE) as a swing bed NF hospital.
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2)
Notify the local SRS income maintenance (IM) worker immediately when an SRS
beneficiary is placed in a swing bed NF. Notification shall be performed by
completing parts I and II of the MS-2126. (Refer to Section 7010.) Once the IM
worker has received the MS-2126, the beneficiary’s case will be budgeted for
long-term care. The hospital will then be notified via a "Notice of Action" as to the
beneficiary’s liability to the hospital while in the swing bed NF. Providers must bill
the full amount and patient liability will be deducted during processing. When billing
for a swing bed, a separate claim must be submitted for each calendar month.
Note: Do not attach a copy of either the MS-2126 or Notice of Action to your claim form.
3)
Bill all NF days for eligible Medicare patients to Medicare first. Medicaid can be
billed for any remaining amounts using the inpatient Medicare claim crossover
method. (Refer to Section 3200.) If Medicare will not pay for the NF days, a copy of
either the Medicare Report of Eligibility (ROE) or a Medicare denial must be attached
to the Medicaid billing supporting nonpayment by Medicare.
4)
Before a transfer to a swing bed NF occurs, the patient must be discharged from the
inpatient unit. Use the appropriate three-digit type of bill code in FL 4 on the UB-04
claim form. (Refer to Section 7000.) Remember, the inpatient unit is not reimbursed
for the date of discharge since the swing bed NF will be reimbursed for the date of
admission.
5)
The appropriate accommodation revenue code applicable to the patient's level of care
shall be entered in FL 42. Bill the total number of days in FL 46 (units). In FL 47,
place the total charge of days billed.
Ancillary charges: Cannot be billed on the swing bed NF claim. Any ancillary
services received by the patient while in a swing bed NF, must be billed on a UB-04
claim form using the outpatient type of bill code (FL 4) and the correct HCPCS code
and revenue code for the ancillary services provided. (See items 7 and 8 for
supplies/services which are content of service for swing bed NF and cannot be billed
separately). Indicate condition code D9 (any other change) in FL 18-28, and enter the
from and through dates of service in FL 6 on the UB-04 claim form. When multiple
dates of service are being billed, enter only the first date of service in FL 45 on the
UB-04 claim form.
Pharmacy: Pharmacy services for swing bed claims need to be billed on a pharmacy
claim form from a Medicaid-enrolled outpatient pharmacy. Refer to the Pharmacy
Provider Manual for billing instructions.
Supplies: When billing for supplies provided by the swing bed facility over and above
the supplies included in the reimbursement rate, use procedure code 99070 - bill one
unit per day. Claims must include both revenue codes and HCPCS codes.
Therapy: Physical, occupational and speech therapy may be billed as outpatient
hospital services for clients in hospital swing beds and long-term care units attached to
hospitals.
6)
With the exception of the billing guidelines addressed above, the remainder of the
claim form is to be completed in the same manner as an inpatient submission. Refer
to instructions in Section 7000 of this manual.
7)
A hospital may not charge Medicaid beneficiaries for providing routine supplies and
services since the hospital is required to provide routine supplies and services to
Medicaid swing bed patients, and the cost of providing routine supplies and services is
included in the hospital's swing bed per diem reimbursement.
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8)
Routine is defined as an item that is commonly stocked for use by anyone. It is an
item that may or may not be specifically assigned or prescribed to any one patient.
Routine items covered by the drug program when ordered by a physician for
occasional use are included in the per diem reimbursement. Since items considered to
be routine for residents of adult care homes are also considered to be routine for
swing bed NF patients, refer to Section 8400 of the Nursing/Intermediate Care
Facility Provider Manual. Any routine item billed on the outpatient hospital claim
form will be denied.
Nonroutine is defined as a specifically prescribed item for a resident for an acute or
chronic need. A medication order may be considered nonroutine if it is not a stock
item of the facility or is a stock item with unusually high usage by the individual.
End Stage Renal Disease
Providers can enroll to perform end-stage renal disease (ESRD) services with KHPA as a
provider type and specialty 30/300 (Renal Dialysis Center).
Outpatient
Note: Outpatient hospital claims which require medical necessity documentation may be billed
electronically. Medical necessity documentation must be retained in the provider's file and made
available for review on a postpay basis. Refer to your EMS Operators Manual for additional
information.
It is not required that providers roll-up their charges into the covered HCPCS code they are billing.
Providers can bill the HCPCS code they are providing, and the processing system will allow the
covered charges and deny the services that are content or noncovered.
Prosthetics and Orthotics
Hospitals must enroll as P&O providers and bill on the professional claim form (CMS-1500)
or 837 professional transaction when providing these services. Contact the Provider
Enrollment Assistance Unit at 1-800-933-6593 or 785-291-4145 (local).
Prosthetic and orthotic items cannot be billed as ancillary services on the UB-04
claim form.
Exception: Prosthesis implanted by a surgical procedure may be billed on the hospital claim
form for inpatient services.
DME Purchase/Rental
All DME services are covered for in-home use only. DME services (purchase or rental) are
noncovered in nursing facilities, swing bed facilities, state institutions, intermediate care
facilities/mental retardation (ICF/MR), psychiatric residential treatment facilities (PRTF),
head injury facilities (HI), rehab facilities, and hospitals.
If the facility receives a per diem rate for a beneficiary, the DME services are considered
content of the per diem and are the responsibility of the facility.
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Emergency Renal Dialysis
Outpatient emergency renal dialysis must be billed utilizing the following diagnosis codes in
FL 67 of the UB-04 claim form.
Diagnosis Codes
5845 - 5849
63630
6393
63430
63730
66930
63530
63830
9585
Emergency Room/Department Services
Enter the time of day (using the continental time system, i.e., 0000-2300) in FL 13,
admission hour.
Emergency services provided in the emergency department must be billed using the
appropriate evaluation and management (E&M) emergency department or critical care
procedure code from the CPT® codebook.
Please reference the CPT® codebook for information on the Centers for Medicare & Medicaid
Services (CMS) and American Medical Association's (AMA) documentation guidelines as
well as directions for assigning codes for emergency services. Copies of "detailed"
documentation guidelines have been published by CMS, Blue Cross & Blue Shield (BCBS),
and the Kansas Foundation for Medical Care (KFMC).
E&M procedure codes applicable to emergency department services include:
99281
99282
99283
99284
99285
99291
99292
Refer to the CPT® codebook for procedure code nomenclature.
Locum Tenens Physicians
• Locum tenens physicians must not be in place for more than one year.
• It is the provider's responsibility to insure a locum tenens physician covering for a KMAP
provider is not excluded from participation in governmental programs including Medicaid.
• Upon review of claims, payments will be recouped if it is determined that KMAP paid for a
service that was provided by a locum tenens physician who was excluded from participation
in governmental programs including Medicaid on the date of service.
Mid-Level Practitioners
Physician assistants (PAs) and advanced registered nurse practitioners (ARNPs) must be
enrolled as Medicaid providers to bill for services. Indicate the PA’s or ARNP’s number as
the attending physician on the UB-04 claim form.
ARNPs and PAs are reimbursed 75 percent of the Medicaid allowed amount for services
provided.
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Modifiers for ER Services
Modifier ET must be added to the base E&M procedure code when billing the hospital
ER/observation room and supplies.
When billing for the hospital-based physician, indicate the base code only (no modifier).
Nonemergency
A revenue code is not required for any outpatient service. Use appropriate HCPCS procedure
codes. In the instance of a nonemergent visit, procedure code 99281 may be used. Submit
only your charges for the hospital-based physician professional fee and covered diagnostic
tests, endoscopic procedures, therapy, etc. Related codes include 99281ET and 99070ET.
Enter the time of day using the continental time system if the services are provided between
6:00 p.m. and 8:00 a.m. (1800 and 0800 hours) in FL 13, admission hour.
Bilateral Procedures
Bilateral procedures performed during the same operative session shall be billed with the
appropriate procedure code. To be consistent with Medicare, if a procedure is identified in the
CPT® codebook as one that should have modifier 50 added when performed bilaterally, bill
the procedure as a single line item with modifier 50. For example, to bill the excision of
bilateral nasal polyps, the provider should indicate procedure code 3011050 on one detail line
on the claim. Reimbursement will be made for the bilateral procedure.
'E' Diagnosis Codes
External causes of injury and poisoning diagnosis ('E') codes are accepted on a claim as a
secondary diagnosis when billed in conjunction with a covered primary diagnosis code.
Observation Room
Procedure cCode 99218 ET should be billed for any service which requires monitoring a
patient's condition beyond the usual amount of time in an outpatient setting. This code shall
not be used to bill for the recovery room.
Sterilization Procedures
When a sterilization is performed in conjunction with, or secondary to an inpatient procedure
(e.g., delivery) and the sterilization is not covered (e.g., failure to obtain the Sterilization
Consent Form), remove all procedure codes and charges related to the sterilization from the
claim and bill the primary procedure only. Carefully document in the medical record the
reason the sterilization was not billed on the claim.
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Physician Clinic Services
Currently, some physicians make scheduled visits once or twice a week to rural hospitals and
see patients in the emergency room which functions as their office. Physician clinic services
provided in a hospital location are considered content of the physician service and should not
be billed to Medicaid or the beneficiary. However, in this instance the hospital can bill
procedure code 99070 for use of room and supplies.
Professional Fees
The only physician services which can be billed by the hospital on the UB-04 claim form are
hospital-based physicians assigned to the emergency department.
Professional/Technical Component Billing
Components: Professional
Enter the HCPCS base code for services rendered, including modifier 26.
(Example: 7207026).
Technical
Enter the HCPCS base code of the service performed, including modifier TC.
(Example: 72070TC). Note: Hospitals billing the base code for radiology
procedures will be reimbursed at the TC rate.
Professional and Technical
Enter the HCPCS base code of the service performed. (Example: 72070)
The same procedures performed on the same day:
• Must be billed on the same claim
• Must clarify the reason for billing more than one procedure (e.g., two x-rays at two
different times; left arm, right arm)
When the same procedures are not billed on the same claim, the additional claim(s) will be
denied as a duplicate.
To seek reimbursement for additional services when this occurs:
Submit an underpayment adjustment using the internal control number (ICN) from the
remittance advice (RA) of the paid claim, and state on the adjustment request that
more than one procedure was performed on the same day. Refer to Section 5600 of
the General Billing Provider Manual for details.
Unit Billing
When billing for outpatient hospital services, round units to the nearest whole
number. Do not bill fractions of units.
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Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other
Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure
Performed on the Wrong Patient
Effective with claims processed on and after February 2, 2010, and retroactive to dates of service on
and after January 15, 2009, the KHPA Medical Plans will not cover a particular surgical or other
invasive procedure to treat a particular medical condition when the practitioner erroneously performs:
1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the
correct procedure but on the wrong patient. Medicaid will also not cover hospitalizations and other
services related to these noncovered procedures. None of the erroneous surgeries or services are
billable to the beneficiary.
All services provided in the operating room when an error occurs are considered related and therefore
are not covered. All providers in the operating room when the error occurs who could bill
individually for their services must submit claims for these services but are not eligible for
reimbursement for these services. All of these providers must submit separate claims for these
services using the appropriate methods.
Inpatient Claims
Hospitals are required to bill two claims when the erroneous surgery(s) is reported.
• One claim with covered service(s)/procedure(s) unrelated to the erroneous surgery(s)
on a type of bill (TOB) 11X (with the exception of 110)
• One claim with the noncovered service(s)/procedure(s) related to the erroneous
surgery(s) on a TOB 110 (no-pay claim)
o The noncovered TOB 110 will be required to be submitted on the UB-04
(hard copy) claim form.
o For claims on and after January 15, 2009, through September 30, 2009,
providers are required to report in form locator (FL) 80 Remarks, one of the
applicable two-digit surgical error codes as follows:
ƒ MX: For a wrong surgery on patient
ƒ MY: For surgery on the wrong body part
ƒ MZ: For surgery on the wrong patient
Providers are required to report as an “other diagnosis” one of the applicable External Cause
of Injury Codes for wrong surgery performed:
• E876.5: Performance of wrong operation (procedure) on correct patient
• E876.6: Performance of operation (procedure) on patient not scheduled for surgery
• E876.7: Performance of correct operation (procedure) on wrong side/body part
Note: These E codes are not to be submitted in the E code field on the UB-04.
Outpatient, Ambulatory Surgical Centers, Other Appropriate Bill Types and
Practitioner Claims
For dates of services on and after July 1, 2009, the providers are required to append one of
the following applicable modifiers to all lines related to the erroneous surgery(s):
• PA: Surgery Wrong Body Part
• PB: Surgery Wrong Patient
• PC: Wrong Surgery on Patient
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Introduction to the UB-04 Claim Form
State institution for mental health providers must use the UB-04 red claim form (or accepted
electronic equivalent) when requesting payment for medical services and supplies provided under the
Kansas Medical Assistance Program. Any UB-04 claim not submitted on the red claim form will be
returned to the provider. An example of the UB-04 claim form is on the public and secure websites
(see the Table of Contents for hyperlinks) in the Forms section at the end of this manual. Instructions
for completing this form are included in the following pages. The Kansas MMIS will be using
electronic imaging and optical character recognition (OCR) equipment. Therefore, information will
not be recognized if not submitted in the correct fields as instructed.
The fiscal agent does not furnish the UB-04 claim form to providers. Refer to Section 1100 of the
General Introduction Provider Manual.
The following numbered form locators (FL) fields are to be completed when required or if applicable.
Billing Instructions:
FL 1
(No Field Name) - Required. Enter the name and address of the billing
provider.
FL 3A
Patient Control No. Enter a patient account number if desired. (This number
will be referenced on the Remittance Advice [RA].)
FL 3B
Medical Record No.-Desired. Enter the patient’s medical record number.
(This number will appear on the provider’s RA.)
FL 4
Type of Bill - Required. Enter the 3-digit number specific to the type of
claim.
1st digit indicates facility. (Always a 2 or 6.)
2nd digit indicates location within facility.
3rd digit indicates the frequency of the claim billed.
Medicaid allowed codes:
1st digit:
1 Hospital (IP/OP)
FL 6
2nd digit:
1 Inpatient
3rd digit:
0
1
2
3
4
Non-payment/zero claim
Admit through discharge claim
Interim - first claim
Interim - continuing claim
Interim - last claim (thru date is discharge date)
Statement Covers Period - From/Through - Required. Enter dates of
admission and discharge from and through dates in MM/DD/CCYY format.
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FL 7
Covered Days - Required - Inpatient Only. Enter the number of days for
which you are billing.
Note: Count date of admission, but not date of discharge.
FL 8B
Patient Name - Required - Enter patient's last name, first name and middle
initial exactly as it appears on the ID card.
FL 10
Birthdate - Required. Enter patient's date of birth in MM/DD/YYYY format
(i.e. October 1, 1957 would be listed as 10/01/1957).
FL 12
Admission Date - Required. Enter date patient was admitted to the facility in
MM/DD/CCYY format.
FL 17
Patient Status - Required - Inpatient Only. Enter a two-digit code to
indicate status of patient:
01
Discharged to home or self care (routine discharge)
02
Discharged/transferred to another short-term general hospital for
inpatient care
03
Discharged/transferred to skilled nursing facility (SNF) with Medicare
certification
04
Discharged/transferred to a facility that provides custodial or
supportive care an Intermediate Care Facility (ICF)
05
Discharge/transfer to a designated cancer center or children’s hospital
06
Discharged/transferred to a home under care of organized home health
service organization
07
Left against medical advice or discontinued care
08
Discharged/transferred to home under care of a home IV drug therapy
provider (This is not a certified Medicare provider.)
09
Admitted as an inpatient to this hospital (for use on Medicare
Outpatient Hospital claims only)
20
Expired (or did not recover - Christian Science Patient)
21
Discharged/transferred to court/law enforcement
30
Still patient
40
Expired at home (hospice claims only)
41
Expired in a medical facility, such as a hospital, SNF, ICF, or
freestanding hospice (hospice claims only)
42
Expired - place unknown (hospice claims only.)
43
Discharge/transferred to a Federal Health Care Facility
50
Discharge to hospice – home
51
Discharge to hospice - medical facility
61
Discharged/transferred to a hospital-based, Medicare-approved,
swing bed
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62
63
64
65
66
70
FL 18-28
Discharged/transferred to an inpatient rehabilitation facility (IRF)
distinct part units of a hospital
Discharged/transferred to a Medicare certified long term care hospital
(LTCH)
Discharge/transferred to a nursing facility certified under Medicaid
but not certified under Medicare
Discharged/transferred to a psychiatric hospital or psychiatric distinct
part unit of a hospital
Discharged/transferred to a Critical Access Hospital (CAH) for
discharge dates on or after January 1, 2006
Discharge/transfer to another type of health care institution not
defined elsewhere in the code list
Condition Codes – Optional. Enter one of these two-digit codes to indicate a
condition(s) relating to inpatient or outpatient claims, special programs or
procedures (e.g. KAN Be Healthy, sterilization, etc.).
Note: This is not a complete list. For a complete list of Condition Codes
contact Customer Service.
01
02
03
67*
80
A1
A4
AA
AB
AI
D9*
Military service related
Condition is employment related
Patient covered by insurance not reflected here
Beneficiary elects not to use life time reserve (LTR) days
*This will now replace the Z1 Medicare Part A benefits
exhausted condition code. The verbiage in the explanation of
condition code 67 means the patient’s benefits are exhausted.
Home Dialysis – Nursing Facility
KAN Be Healthy (EPSDT)
Family Planning
Abortion performed due to rape
Abortion performed due to incest
Sterilization
Any other change
*This will now replace the XO swing bed condition code.
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FL 31-34
Occurrence Codes/Dates: OCCURRENCE CODES CAN ONLY BE
SUBMITTED ON LINE A.
The following occurrence codes must be indicated if reporting information on
type of accident, crime victim, other insurance denial or date of TPR
termination, or aborted surgery, false labor or nondelivery claim where
associated services are indicated.
Note: This is not a complete list. For a complete list of Occurrence Codes
contact Customer Service.
01
02
03
04
05
06
24
25
A3
B3
C3
Accident/medical coverage
No fault insurance involved – including auto accident/other
Accident/tort liability
Accident/employment related
Accident/no medical or liability coverage
Crime victim
Date insurance denied
Date benefits terminated by primary payer
Benefits exhausted, Payer A
Benefits exhausted, Payer B
Benefits exhausted, Payer C
All fiscal agent/KHPA SRS guidelines remain the same regarding attachments
required for TPR proof and SSA/Medicare EOMBs.
FL 39
Value Codes/Amount – Required if applicable.
• Enter D3 for nonpatient obligation as the value code. Enter the
nonpatient obligation dollar amount in the Amount field. Examples of
nonpatient obligation are Parental, Spousal, and Trust.
• Enter 80 for covered days and enter the number of covered days in the
Amount field.
Note: Count the date of admission but not the date of discharge.
*FL 42
Revenue Code – Required. Enter the three-digit code identifying the type of
accommodation services. Use only the revenue codes listed below:
101 All inclusive room and board
180 NF/MH reserve days
181 Home therapeutic reserve days ICF/MH – 21 days per calendar
year
183 Home leave days / Therapeutic leave days
185 Hospital leave days
189 Noncovered days
*FL 45
Service Date – Required. Enter first date of service for the detail line.
*FL 46
Service Units - Required. Enter the total number of days for each detail line.
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FL 47
Total Charges - Required. Enter total charges billed.
FL 50
Payer Name - Required. Enter all third party resources (TPR). If TPR does
exist, it must be billed first. Lines B and C should indicate secondary and
tertiary coverage. Medicaid will be either the secondary or tertiary coverage
and the last payer. When B and C are completed, the remainder of this line
must be completed as well as FL 58-62. Medicare needs to always be the
last entry.
FL 54
Prior Payments - Required if other insurance is involved. Enter amount
paid by other insurance. Medicare needs to always be the last entry. Do not
enter patient liability amount. It is automatically deducted during claim
processing.
FL 57
Other Provider ID: Enter either qualifier ‘1D’ and the billing provider’s
KMAP provider ID or qualifier ‘ZZ’ and the taxonomy code.
FL 60
Insured’s Unique ID: Enter the 11-digit number from the beneficiary’s
medical card on line C.
FL 61-62
Group Name/Insurance Group No. - Required if Medicaid is not primary
payer. Enter the primary insurance information on line A and Medicare on
line C.
FL 67A-Q
Prin. Diag. Cd. - Required. Enter the ICD-9-CM code indicating the
primary diagnosis and additional diagnoses.
FL 76
Attending - Optional.
a. Enter attending physician's NPI, or the appropriate qualifier and
physician’s KMAP provider ID or taxonomy code.
b. Enter attending physician's Medicaid provider name as last name and then
first name.
FL 80
Remarks – Optional. Specify additional information as necessary.
Submission of Claim:
Send completed claim to:
Kansas Medical Assistance Program
Office of the Fiscal Agent
P.O. Box 3571
Topeka, Kansas 66601-3571
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BILLING INSTRUCTIONS
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7030. Updated 10/09
STATE INSTITUTION FOR M/H SPECIFIC BILLING INFORMATION
Accommodation and Ancillary Charges
If the individual accommodation and ancillary services exceed the detail lines on the UB-04
claim form, providers may combine all similar revenue code charges together (e.g., lab,
radiology) when necessary. Accommodation codes may also be 'lumped' together when
necessary. This will not affect the reimbursement of the claim.
State institutions may bill for ancillary services without indicating an accommodation code.
Medicare B Services
When Medicare B payment is made on an inpatient claim, indicate the amount paid as Prior
Payment in FL 54 on the UB-04 claim form.
Other Insurance
When a beneficiary has other insurance, proof of payment or denial is required. Enter the
amount paid by the other insurance carrier in FL 54 on the claim form. Refer to Section 3300
of the General Third Party Payments Provider Manual for specific instructions on submitting
claims when other insurance is involved.
Patient/Parental Liability
Indicate any patient or parental liability in FL 54 on the UB-04 claim form. Payment will be
deducted accordingly.
Transfers
When billing medically necessary incoming transfers, the following should be entered on
claims for incoming transfers from other hospitals:
In FL 84, Remarks, enter "direct transfer from (hospital, city)."
Reserve Days
Indicate revenue code 189 in FL 42 when billing for reserve days.
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BENEFITS AND LIMITATIONS
8100. COPAYMENT Updated 10/09
General hospital inpatient services require a copayment of $48 per inpatient admission.
General hospital outpatient surgery requires a copayment of $3 per surgery.
General hospital nonemergency outpatient services in place of a doctor's office visit require a
copayment of $3 per visit.
Ambulatory surgical center services require a copayment of $3 per day.
Inpatient free standing private psychiatric facility services require a copayment of $48 per
admission.
Specialty hospital (rehabilitation facilities, teaching facilities, etc.) inpatient services require a
copayment of $48 per inpatient admission.
State psychiatric facility beneficiaries are exempt from copayment requirements.
Transferring inpatient hospital admissions are exempt from copayment requirements. Copayment
will be deducted from the receiving hospital.
Bill all services occurring on the same date on the same claim form. If multiple claims are submitted
for the same date(s) of service, the copayment requirement will be deducted for each claim submitted.
Do not reduce charges or balance due by the copayment amount. This reduction will be made
automatically during claim processing.
Refer to Section 3000 of the General Third Party Payments Provider Manual for exceptions.
KANSAS MEDICAL ASSISTANCE PROGRAM
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BENEFITS AND LIMITATIONS
8200.
MEDICAL ASSESSMENT Updated 08/07
Documentation:
To verify services provided in the course of a postpayment review, documentation in the
patient's medical record must support the service billed. Documentation can be requested at
any time to verify that services have been provided within program guidelines. Refer to
Section 5000 of the General Billing Provider Manual. Autoauthentication (computerized
authentication) of documentation for the medical record is acceptable documentation for the
Kansas Medical Assistance Program. Autoauthentication must meet federal guidelines. It
may be necessary to contact the ordering physician for medical necessity information.
Federal regulation 42 CFR 482.24 (c) (1) (i) requires that there must be a method of
determining that the physician authenticated the document after transcription. All entries must
be legible and complete and must be authenticated and dated promptly by the person
(identified by name and discipline) who is responsible for ordering, providing, or evaluating
the service furnished. The author of each entry must be identified and must authenticate his
or her entry. Authentication may include the author's signature, written initials, or computer
entry.
The information below indicates medical information which may be necessary to document
medical necessity of those diagnoses designated as “sometimes payable” on the screen.
Abdominal Plain Films and Ultrasound:
Abdominal plain films and ultrasound are medically necessary if the diagnosis indicates
abdominal pain, nausea/vomiting, complications associated with ulcers, intestinal obstruction,
gall bladder disease, malignant neoplasm of the abdominal organs, injury to the abdomen or
nephrolithiasis. It may be necessary to contact the ordering physician for medical necessity
information.
An abdominal plain film may be warranted in a pregnant patient if:
• Fetal position is questionable.
• Obstetrical ultrasound is unavailable and patient is in labor.
Electrocardiograms (EKGs):
Electrocardiograms (up to 12 leads) are considered medically necessary when the diagnosis
and/or condition clearly indicates one or more of the following:
• Relevant cardiopulmonary diagnosis
• Significant electrolyte imbalance
• Drug induced EKG changes (identify the drug)
• Progressive renal disease
• Unstable thyroid disease
• Specific central nervous system (CNS) disorders causing EKG changes
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•
•
•
•
•
Congenital disorders causing EKG changes
Symptomatic hypothermia
Shortness of breath
Fainting spells
Monitoring the effects of psychotropic drugs for potential cardiac effects
(identify the drug)
Preoperative EKGs are medically necessary for patients over age 40, or those patients under
40 with a history of cardiac problems. It may be necessary to contact the ordering physician
for medical necessity information.
Cardiac Rehabilitation:
Phase II Cardiac Rehabilitation is covered using procedure code 93798. This procedure is
covered when performed in an outpatient or cardiac rehabilitation unit setting, with the
following criteria:
• Beneficiary must have a recent cardiology consultation within three months of
starting the cardiac rehabilitation program.
• Beneficiary must have completed Phase I Cardiac Rehabilitation.
• Beneficiary must have one or more of the following diagnoses/conditions:
o Acute myocardial infarction (410.00 – 410.92, 414.8) within the
preceding three months, post inpatient discharge
o Coronary bypass (V45.81) surgery within the preceding three months,
post inpatient discharge
o Stable angina pectoris (413.9 and 413.0) within three months post
diagnosis
Chest X-Rays:
Chest X-rays are determined medically necessary if:
• History or indication of cardiopulmonary disease, malignancy, cardiovascular
accident (CVA), or long bone fracture
• Recent thoracic surgery
• Thoracic injury
• Chronic cough of over one month duration
o (Specify as chronic in the diagnosis field. If this designation is not
supplied, the condition will be considered acute and the X-ray
denied.)
Pre-operative and routine admission chest X-rays are noncovered unless documentation of
medical necessity (one or more of the following factors) is noted on the claim:
• Sixty years of age or older
• Pre-existing or suspected cardiopulmonary disease
• Smoker over age forty
• Acute medical/surgical conditions such as malignancy or trauma
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Claims denied because other factors are listed, will be reconsidered if appealed (refer to
Section 5300 of the General Billing Provider Manual).
It may be necessary to contact the ordering physician for medical necessity information.
CT Scans - Abdominal
A CT scan of the abdomen is medically necessary if the diagnosis indicates a malignant
neoplasm of the intra-abdominal cavity, lung or genital organs, lymphoma, diseases of the
spleen, liver abscess, peritonitis, pancreatitis, abdominal trauma, or abdominal mass.
A CT scan of the abdomen may be medically necessary for abdominal pain, abdominal
aneurysm, acute lymphocytic leukemia, or any malignant neoplasm not located in the
intra-abdominal cavity, lung or genital organs. Inclusion of the following documentation will
assist in the adjudication of your claim.
Abdominal Pain: Indicate the severity and chronicity of the pain, presenting
symptoms and suspected conditions or complications.
Abdominal Aneurysms: Indicate the presenting symptoms and suspected
complications.
Acute Lymphocytic Leukemia: Indicate the presenting symptoms and a detailed
description of area(s) involved.
Malignant Neoplasm Not Located in the Intra-Abdominal Cavity, Lung or Genital
Organs: Indicate pertinent symptoms and if performed as part of staging the
disease process.
It may be necessary to contact the ordering physician for medical necessity information.
CT Scans - Head or Brain
A CT scan of the head or brain is medically necessary if the diagnosis indicates intracranial
masses/tumors, intracranial congenital anomalies, hydrocephalus, brain infarcts, parencephalic
cyst formation, open or closed head injury, progressive headache with or without trauma,
intracranial bleeding, aneurysms, or the presence of a neurological deficit.
A CT scan of the head or brain may also be medically necessary with the indication of
headache, epilepsy, syncope, dizziness, or acute lymphocytic leukemia. Inclusion of the
following documentation will assist in adjudication of your claim:
Headache - Indicate length of chronicity and any accompanying central nervous
system (CNS) symptoms.
Epilepsy - Specify if initial or repeat scan, indicate if suspected injury occurred
during seizure.
Syncope - Specify if recurrent or single episode.
Dizziness - Specify if recurrent or single episode.
Acute Lymphocytic Leukemia - Indicate any accompanying CNS symptoms.
It may be necessary to contact the ordering physician for medical necessity information.
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Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy is a covered service under KMAP with PA. The following criteria
must be met before a PA will be approved.
1. The services must be for one of the following conditions:
a. Acute carbon monoxide intoxication
b. Decompression illness
c. Gas embolism
d. Gas gangrene
e. Acute traumatic peripheral ischemia
f. Compromised skin grafts
g. Chronic refractory osteomyelitis
h. Osteoradionecrosis
i. Soft tissue radionecrosis
j. Cyanide poisoning
k. Actinomycosis
l. Crush injuries and suturing of severed limbs
m. Progressive necrotizing infections
n. Acute peripheral arterial insufficiency
o. Diabetic wounds of lower extremities
2. It must be documented that other treatments have been attempted with no
improvement.
Facilities can bill for this procedure using procedure codes 99183 or C1300 (one unit equals
30 minutes with a maximum of four units allowed per treatment session) (four units equals
one session, up to two hours). The facility must choose which procedure code they will bill
prior to the approval of the PA.
If there are multiple treatment sessions on the same day (more than four units for facilities),
each subsequent session must be billed on a separate detail line with a 76 modifier.
MRI - Head or Brain
MRI scan of the head or brain is medically necessary if the diagnosis indicates intracranial
injury, intracranial mass/tumor, CNS malignancies, cerebrovascular disorder, cerebral
malformations, disorders of the cerebral hemispheres and higher brain functions,
demyelinating diseases, extrapyramidal and cerebellar disorders, brain abscesses, encephalitis,
tuberculous meningitis, or the presence of a neurological deficit.
MRI scan of the head or brain may also be medically necessary with the indication of
headache, seizure disorders, syncope, dizziness, or non-CNS malignancies. Inclusion of the
following information will assist in adjudication of your claim:
Headache - Indicate length of chronicity and any accompanying neurologic symptoms.
Seizure - Specify if initial or repeat scan, and if seizures (or convulsions) are of disorders
(or convulsions) are of recent onset, frequency of their occurrence, and any accompanying
neurologic symptoms.
Syncope - Specify if recurrent or single episode and any accompanying neurologic
symptoms.
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Dizziness - Specify if recurrent or single episode and any accompanying neurologic
symptoms.
Non-CNS Malignancies - Indicate any accompanying neurologic symptoms.
It may be necessary to contact the ordering physician for medical necessity information.
MRI - Breast
MRI of the breast will be covered with the following indications:
• Staging and therapy planning in patients diagnosed with breast cancer
• Occult primary breast cancer when there are positive axillary nodes and no known
primary tumor
• Inconclusive diagnosis after a standard mammography evaluation, for example
when scar tissue from previous surgery, dense breast tissue of breast implants
render mammographic images inconclusive
MRI used for screening for breast cancer is not justified.
Skull X-Rays
Skull X-rays are medically necessary if diagnosis indicates cranial trauma, primary or
metastatic tumors of the skull, or tumors of the pituitary gland.
A skull X-ray may also be medically necessary for indication of chronic sinusitis, trigeminal
neuralgia, or anomalies relating to the head. Inclusion of the following documentation will
assist in the adjudication of your claim:
Chronic Sinusitis - Indicate any pertinent specific suspected complications resulting
from chronicity.
Trigeminal Neuralgia - Specify type of lesion suspected.
Anomalies relating to the head - Specify if done as a scout film for non-cosmetic
reconstructive surgery. Indicate type of surgery under consideration.
It may be necessary to contact the ordering physician for medical necessity information.
Sonograms - Non-Obstetrical Pelvic
Non-obstetrical pelvic sonograms are determined medically necessary if the diagnosis indicates
pelvic mass or pain, ovarian cyst, pelvic inflammatory disease, endometriosis, possible
retained products of conception, or question/history of metastatic disease.
Non-obstetrical pelvic sonograms may be medically necessary if there is an indication of
vaginal bleeding or irregular menstrual cycles.
It may be necessary to contact the ordering physician for medical necessity information.
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BENEFITS & LIMITATIONS
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Obstetrical Pelvic Sonograms
Routine obstetrical sonograms for a normal pregnancy are not covered.
One routine sonogram will be covered per fetus per pregnancy using the diagnoses V220V222. A routine obstetrical (OB) sonogram will not be covered if the sonogram is performed
solely to determine the fetal sex or to provide parents a view and photograph of the fetus.
Primary diagnosis shall support medical necessity for an OB sonogram. Some examples are:
indication of vaginal bleeding, multiple birth, diabetes, size/date discrepancy, fetal anomalies,
threatened abortion, placental/uterine abnormalities, fetal demise, maternal
drug/alcohol/tobacco use, or history of previous miscarriage, Cesarean Section, stillbirth,
ectopic pregnancy, eclampsia, or intra-uterine growth retardation.
Medical necessity may also be determined based on maternal age, maternal weight, or fetal
position. If applicable, this information should be submitted with the claim.
It may be necessary to contact the ordering physician for medical necessity information.
A biophysical profile will not be reimbursed when a complete OB sonogram has been billed
for the same date of service.
Upper Gastrointestinal Series
Upper Gastrointestinal (UGI) series are medically necessary if the primary diagnosis indicates
persistent dysphagia, melena, symptoms of UGI tract bleeding or signs and symptoms of
ulcers affecting the UGI tract after a trial of medicinal therapy has failed to relieve the
symptoms. State guidelines allow one UGI series per day, per beneficiary, regardless of
provider.
UGI series may also be medically necessary when diagnoses such as abdominal pain and
dyspepsia are used. When these common nonspecific diagnosis codes are used, additional
symptoms and/or circumstances that relate to the medical necessity of the procedure must be
indicated. Examples of additional information which will assist in adjudication of your claim
are as follows:
• Is the symptom persistent? If so, how long has the symptom persisted?
• Is the symptom recurrent? When was the last episode?
• Has the symptom or condition increased in severity?
• Was medicinal therapy initiated prior to any procedure being performed? If so, indicate
the date each therapy was initiated, name(s) of medication (list all GI related medications
tried) and the length of time each medication was tried. What was the patient's response
to each treatment?
• If a chronic condition, has there been a change in symptoms? If so, describe the
change(s).
• If cancer diagnosis codes are used, what symptoms are present that indicate UGI
involvement?
Claims for UGI X-rays are denied reimbursement when the diagnosis code on the claim is
either too nonspecific or is the result, rather than the reason, for the procedure. Whenever
possible, use the symptoms that most clearly describe the reason for the test.
It may be necessary to contact the ordering physician for medical necessity information.
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HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
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Emergency Room/Department (Outpatient Hospital):
General Information:
The State of Kansas defines emergency services as follows:
KAR 30-5-58 (42) "Emergency services are those services provided after the sudden
onset of a medical condition manifested by symptoms of sufficient severity, including
severe pain, that the absence of immediate medical attention could reasonably be
expected to result in placing the patient's health in serious jeopardy, serious
impairment of bodily functions, or serious dysfunction of any bodily organ or part."
KAR 30-5-81 (b) (4) "Services provided in the Emergency Department shall be
emergency services."
Emergency status is determined based on conditions relating to the emergency visit, not the
patient's age and time of admission to the emergency department. Emergency department
claims are limited to one visit per beneficiary, per date of service unless accompanying
documentation verifies the necessity for more than one emergency room/department visit.
Direct physical attendance by a physician or mid-level practitioner is required in "emergency"
situations. If the physician or mid-level practitioner has not made entries on the record other
than his/her signature and/or diagnosis and documentation does not indicate that he/she had
examined the patient, the visit will not be considered emergent. Phone or standing orders do
not support emergency treatment.
Axillary temperatures are not considered accurate and will be disregarded when determining
emergent status.
Beneficiaries may go to the emergency room without a referral from their physician based on
the definition of an emergency according to a prudent layperson (as defined by the Balanced
Budget Act, 1997): What a layperson would consider an emergency in the absence of
medical knowledge. Such an emergency could include, but is not limited to: serious
impairment to bodily functions; serious dysfunction of any bodily organ or part; severe pain;
or an injury/illness that places the health of the individual in serious jeopardy (and in the case
of a pregnant woman, her health or that of her unborn child).
Other Examples of Emergencies are:
o Initial treatment for medical emergencies including indications of severe chest pain,
dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness,
status epilepticus or other conditions considered "life-threatening."
o Patients who require transfer to another facility for further treatment or who expire.
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Nonemergent Situations:
o Intentional non-compliance with previously ordered medications and treatments
resulting in continued symptoms of the same condition.
o Refusal to comply with currently ordered procedures/treatments such as drawing
blood for laboratory work.
o Leaving the emergency room against medical advice.
o Scheduled visits to the emergency room for procedures, examinations or medication
administration. Examples include cast changes, suture removal, dressing changes,
follow-up examinations and second opinion consultations.
o Visits made to receive a "tetanus" injection in the absence of other emergent
conditions.
o Visits made to obtain medication(s) in the absence of other emergent conditions.
The following conditions will not be considered emergent unless the criteria described has
been met:
Alcoholism in and of itself is considered nonemergent unless documentation supports an
emergent status (i.e., gastric bleeding or coma/stupor).
Ambulance: A patient brought in by ambulance does not necessarily justify an emergency
room visit.
Guidelines for Use of Air Ambulance Services:
Time: If time is a critical factor in the patient’s recovery or survival, or duration of
ground transport would be excessive and potentially detrimental, air transport may be
indicated. In general, if the ground ambulance can arrive at the destination institution
within 20 minutes, it is the preferred mode of transport.
Expertise: If the health care institution does not possess the expertise to provide the
definitive care required to stabilize the patient (i.e., advanced life support) and the
ground ambulance providers in the near vicinity cannot provide assistance in
providing that care, air transport may be indicated.
Coverage: If ground ambulance utilization leaves the service area without adequate
ground coverage and patient outcome will be compromised by arranging other ground
transport, air transport may be indicated.
Documentation: The above guidelines serve as a guide to documentation which is
necessary to determine proper reimbursement and must specify the indication and
justification for air transport. If guidelines are not met, or are met but not
documented, the billed transportation will be reimbursed at ground ambulance rates or
denied altogether.
Depression/Anxiety: Documentation must support the individual to be an immediate danger
to self or others.
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Disposition: If a patient's disposition is one of the following, the visit would be considered
emergency:
a)
requires transfer to another facility for further treatment,
b)
has expired, expires enroute to the hospital or in the emergency room,
c)
requires extended observation or admission.
Fevers must be considered with other documented symptoms. Generally, temperatures less
than 103 rectally (children) or 102 orally (adults) are not considered emergent. Ear and
axillary temperatures will be considered along with additional symptoms. Reported
temperatures by patients are not acceptable for determining emergent status.
Insect Bites, Stings, Embedded Ticks: Minor insect bites (tick) with simple local reactions
only (i.e., erythema, local edema, itching) are not considered emergent.
Medical Emergency: Initial treatment and/or stabilization for medical emergencies including
indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion,
loss of consciousness, status epilepticus or other conditions considered "life-threatening"
would be considered emergent. Just because these conditions may be considered "lifethreatening" at times, does not automatically indicate a Level of Care III. The Level of Care
assignment is dependent upon the severity of the situation and the services provided.
Mental Disorders such as depression or anxiety as an individual diagnosis is considered
nonemergency unless the patient is noted to be suicidal or of immediate risk to self or others.
Minor Burns/Sunburns: Minor burns/sunburns are considered nonemergent unless
documentation supports the presence of complications such as severe swelling, infection, or
the young age of the patient. Eye and chemical burns are considered emergent.
Otitis Media: If tympanic membrane is bulging or ruptured, drainage from the ear(s), fever
of 103 or above or is a child of age 3 or under and is crying inconsolably, a visit to the
emergency room would be considered emergent for consideration of otitis media. If the
physical examination reveals evidence of acute otitis media (after office hours or on the
weekend), but does not meet any of the above criteria, the ED visit may be considered
emergent because of the time of day/week.
Patient Noncompliance: Intentional noncompliance with previously ordered medications and
treatments resulting in continued symptoms of the same condition are considered
nonemergent. Refusal to comply with currently ordered procedures/treatments such as
drawing blood for laboratory work will also be considered nonemergent.
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Removal of Cutaneous Foreign Bodies: Removal of cutaneous foreign bodies (i.e., simple
splinters, cactus needles) are considered nonemergent unless sedation or the use of extensive
medical supplies such as cutdowns are required.
Seizures are considered emergent when:
a)
this is an initial seizure
b)
there is a secondary diagnosis noted (i.e., infection or headache)
c)
the patient is 12 years old or younger
d)
the seizure is still in progress or status epilepticus
e)
this is a febrile seizure
f)
the condition is aggravated by alcohol/drug ingestion
g)
this is a previously undiagnosed condition
Scheduled Visits: Scheduled visits to the emergency department for procedures,
examinations or medication administration (i.e., cast changes, suture removal, dressing
changes, follow-up examinations and second opinion consultations) are considered
nonemergent.
When a patient leaves the emergency department against medical advice (AMA) the service is
generally considered nonemergent. However, if the facility provided considerable services
before the patient left AMA, the visit will be given consideration as emergent.
Sickle Cell Anemia: If a person has sickle cell anemia and presents with suspicion of an
infectious or hypoxic process, or complains of pain, the visit may be considered emergent.
Skin Rash/Hives: Documentation must support presence of systemic complications beyond
the local skin discomforts resulting from the rash. If the rash causes eye complications or the
beneficiary has a history of anaphylactic (allergic) reactions, the visit is considered emergent.
If the rash causes eye edema or impairment to eye function and the visit is over a weekend
when there is no access to a physician's office, the visit may be considered emergent.
A history of anaphylaxis along with the rash is considered emergent.
Trauma/Injury: Recent trauma or injury is considered emergent. Recent is defined as an
injury occurring within 48 hours prior to the emergency room visit. Minor
abrasions/lacerations not requiring suture or other injuries not requiring treatment are not
emergent.
If the injury is older than 48 hours and symptoms have deteriorated to the point of requiring
emergency care, consider as emergent.
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An injury that requires only simple first aid treatment that can be done in the home (such as
cleansing and/or bandaging an abrasion) is not considered emergent.
A laceration requiring steri-strips indicates a gaping wound and would be considered
emergent.
X-rays do not define the level of care.
Tetanus Injection: A tetanus injection is not considered emergent and does not change the
visit to emergent. However, the patient should not have to make two visits (one to the
emergency room and one to an office or public health department) in order to receive the
tetanus injection. When needed, a tetanus injection should be given within 48-72 hours of the
injury, if possible.
Time of Visit: The time of the visit is a consideration in determining emergent vs.
nonemergent status. If the condition require immediate attention and it is after office hours, a
weekend, or holiday, consider as emergent.
If a patient is brought in by the police at any time, consider as emergent.
If a patient had previously been in the same or different emergency department or physician's
office for the same condition and the condition has not worsened, the visit will be considered
nonemergent.
Vital Signs: If the vital signs are outside a reasonable range for the age, consider the visit as
emergent (see "fever").
Emergency Department/Room Guidelines for E&M Codes
History: The age of a patient is a component of every medical record. Documentation of age
in relationship to issues such as antisocial behavior or mental status is important; however,
age alone is not considered a social history.
Examination: A "comprehensive exam" is considered a "hands on" specialist examination.
Telephone consultation with a specialist is not the equivalent of comprehensive exam (per Dr.
Aaron Primack, HCFA/AMA consultant).
Medical Decision Making: Transfers from the emergency department to another facility for
additional care should be considered in management options as either the "new problem,
additional work-up" or the category of "established problem, worsening" (per Dr. Aaron
Primack, HCFA/AMA consultant).
A vascular examination is included in the cardiovascular category.
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A notation that the patient should "follow-up" with his family physician in the morning or
return to the physician's office for stitch removal does not justify use of the "additional workup" statement when considering management options (per Dr. Aaron Primack, HCFA/AMA
consultant).
In evaluating the "Table of Risk", infection is the usual risk that pops into mind when talking
about minor surgery. To consider infection as a "risk" from minor surgery, there must be
documentation to support increased risk due to the quality or condition of the injury or illness
(per Dr. Aaron Primack, HCFA/AMA consultant).
"Self-limited/minor problems" are defined as those representative of basic emergency
department care such as lacerations, stings, insect bites (per Dr. Aaron Primack,
HCFA/AMA consultant).
"New problems with or without additional work-up" is defined as representing new, longstanding problems that will need attention again at some time (per Dr. Aaron Primack,
HCFA/AMA consultant).
Observation Room:
Observation in the outpatient setting is a service which requires monitoring the patient's
condition beyond the usual amount of time in an outpatient setting. Examples of the
appropriate use of the observation room include: monitoring head trauma, drug overdose,
cardiac arrhythmias and false labor. A physician or mid-level practitioner must see the patient
within two hours prior to admission to the observation room except for obstetrical labor or
scheduled administration of IV medication or blood products. The observation room stay must
be medically necessary.
There is no time limit restriction for the observation room. The same reimbursement rate
applies regardless of the number of hours required for monitoring. This reimbursement is all
inclusive of services and supplies. If there is a discharge and readmission to the observation
room from midnight to midnight, only one reimbursement rate will be allowed.
Observation room is content of service of a minor surgery.
ER physician fee, nonscheduled fetal oxytocin stress tests and fetal nonstress tests are content
of service of the observation room. Additional reimbursement for these services will not be
made.
Observation room should not be billed for the following:
o Recovery room services following inpatient or outpatient surgery.
o Recovery/observation following scheduled diagnostic tests such as arteriograms,
cardiac catherization, etc.
o Scheduled fetal oxytocin stress tests and fetal nonstress tests.
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NOTE:
Additional information may be added to the face of your claim if
applicable. Electronic Tape billers who have had initial billings denied
with EOB 548 (Service denied. This claim and all attachments have been
reviewed by the medical staff and the medical necessity of the service
rendered is not supported by the documentation provided. Refer to the
provider manual section 8200 for further discussion.), may resubmit a
paper claim with the applicable documentation noted on the face of
the claim.
If the claim and/or attachments do not support the medical necessity of the
service rendered, the service will be denied.
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BENEFITS AND LIMITATIONS
8300. Benefit Plans Updated 05/09
KMAP beneficiaries will be assigned to one or more benefit plans. These benefit plans entitle the
beneficiary to certain services. If there are questions about service coverage for a given benefit plan,
refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of
Kansas Medical Card and eligibility verification.
For example, all policies and coverages under the current Medicaid program apply to the MediKan
benefit plan except:
• Inpatient general hospital services are covered for MediKan beneficiaries for the following
conditions only:
• Acute psychotic episodes
• Alcohol and drug detoxification
• Burns
• Severe acute traumatic injuries
• Tuberculosis
•
MS-DRGs for covered inpatient hospital services are:
183-185 483-484 880-887 913-914 927-934 955-965
Additional MS-DRGs (094-096) are covered when the hospital admission is related to
tuberculosis (TB) and a TB diagnosis is billed on the claim.
•
Claims for MediKan
reviewed:
003-004 011-030
199-201 228-230
456-465 469-473
659-661 707-712
901-909 917-918
beneficiaries that group to any of the following MS-DRGs will be
037-039
237-241
480-482
746-747
922-923
052-053
252-257
485-508
799-804
935
082-090
329-334
510-538
853-855
113-117
344-346
562-563
856-863
129-139
368-373
604-605
876
163-176
377-379
653-655
894-897
Coverage determination is based on the nature of the injury indicated by the diagnosis on the
claim and by the medical documentation submitted.
Note: If medical documentation is not submitted, the claim will be denied.
Note: Severe acute traumatic injury definition: Physical harm to a person’s body by an outside force
that requires immediate hospitalization and medical interventions for the preservation of life and
function.
Psychiatric Admissions
The only psychiatric services covered are those for acute psychotic episodes. Inpatient
psychiatric admissions to acute care general and specialty hospitals are covered only after a
psychiatric preadmission assessment has been completed and a determination made that the
most appropriate treatment setting is the hospital. Only the following psychiatric diagnosis
codes are covered for MediKan beneficiaries:
293.00 - 293.90
295.00 - 295.90
296.00 - 296.99
298.00 - 298.90
299.00 - 299.90
300.00 - 300.90
307.00 - 307.90
Coverage determinations are based on the emergent nature of the service.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-15
BENEFITS AND LIMITATIONS
8400. MEDICAID - INPATIENT/OUTPATIENT Updated 10/09
Enrollment
Hospitals must sign a Hospital/Peer Review Organization Agreement with the Utilization
Review Contractor before becoming enrolled as a KHPA Medical Plans provider.
Change of Ownership
Each hospital must notify Provider Enrollment the Adult and Medical Services, SRS, in
writing at least 60 days prior to the change of ownership closing transaction date. Failure to
do so may result in:
• The forfeiture of rights to payment for covered services provided to beneficiaries by
the previous owner or owners in the 60-day period prior to the effective date of the
change of ownership.
• The new owner or owners assuming responsibility for any overpayment made to
previous owner(s) before the effective date of the change of ownership. (This shall not
release the previous owner of responsibility for such overpayment.)
The new owner (and affiliated providers) must apply for a Medicaid provider number through
the Adult and Medical Services by contacting Provider Enrollment at:
Provider Enrollment
PO Box 3571
Topeka, KS 66601-3571
Department of Social and Rehabilitation Services
Adult and Medical Services, Medical Programs
The Docking State Office Building, 6th Floor
915 S.W. Harrison
Topeka, Kansas 66612
The new owner will receive the full reimbursement for any patients admitted before and
discharged after the change of ownership effective date. The old owner shall not receive
Medicaid payment for these services.
Advance Directives
Hospital providers participating in the KHPA Medical Plans must comply with federal
legislation (OBRA 1990, Sections 4206 and 4751) concerning advance directives. An
"advance directive" is otherwise known as a living will or durable power of attorney. Every
hospital provider must maintain written policies, procedures and materials about advance
directives.
Specific Requirements
1. Each hospital must provide written information to every adult individual receiving
medical care by or through the hospital. This information must contain:
• The individual's right to make decisions concerning his or her own medical
care
• The individual's right to accept or refuse medical or surgical treatment
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-16
8400. Updated 10/09
•
•
2.
3.
4.
5.
6.
The individual's right to make advanced directives
SRS’ "Description of the Law of Kansas Concerning Advance Directives"
Note: SRS does not provide copies of the description to providers. It is up to
providers to reproduce the description. Providers are free to supplement this
description as long as they do not misstate Kansas law.
Additionally, each hospital must provide written information to every adult individual
about the hospital's policy on implementing these rights.
A hospital must document in every individual's medical record whether the individual
has executed an advance directive.
A hospital may not place any conditions on health care or otherwise discriminate
against an individual based upon whether that individual has executed an advance
directive.
Each hospital must comply with state law about advance directives.
Each hospital must provide for educating staff and the community about advance
directives. This may be accomplished by brochures, newsletters, articles in the local
newspapers, local news reports or commercials.
Incapacitated Individuals
An individual may be admitted to a facility in a comatose or otherwise incapacitated state, and
be unable to receive information or articulate whether he or she has executed an advance
directive. If this is the case, families of, surrogates for, other concerned persons of the
incapacitated individual must be given the information about advance directives. If the
incapacitated individual is restored to capacity, the hospital must provide the information
about advance directives directly to him or her even though the family, surrogate or other
concerned person received the information initially.
If an individual is incapacitated, otherwise unable to receive information or articulate whether
he or she has executed an advance directive, the hospital must note this in the medical record.
Mandatory Compliance with the Terms of the Advanced Directive
When a patient, relative, surrogate or other concerned/related person presents a copy of the
individual's advance directive to the hospital, the facility must comply with the terms of the
advance directive to the extent allowed under state law. This includes recognizing powers
of attorney.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-17
8400. Updated 11/03
Description of the Law of Kansas Concerning Advance Directives:
There are two types of "advance directives" in Kansas. One is commonly called a "living
will" and the second is called a "durable power of attorney for health care decisions."
The Kansas Natural Death Act, K.S.A. 65-28,106, et seq.
This law provides that adult persons have the fundamental right to control decisions
relating to their own medical care. This right to control medical care includes the
right to withhold life-sustaining treatment in case of a terminal condition.
Any adult may take a declaration which would direct the withholding of life-sustaining
treatment in case of a terminal condition. Some people call this declaration a "living
will." The declaration must be:
1.
In writing;
2.
Signed by the adult making the declaration;
3.
Dated; and
4.
Signed in front of two adult witnesses, or notarized.
There are specific rules set out in the law about the signature in case of an adult who
can't write. There are specific rules about the adult witnesses. Relatives by blood or
marriage, heirs, or people who are responsible for paying for the medical care may
not serve as witnesses. A woman who is pregnant may not make a declaration.
The declaration may be revoked in three ways:
1.
By destroying the declaration;
2.
By signing and dating a written revocation; and
3.
By speaking an intent to revoke in front of an adult witness. The
witness must sign and date a written statement that the declaration was
revoked.
Before the declaration becomes effective, two physicians must examine the patient and
diagnose that the patient has a terminal condition.
The desires of a patient shall at all times supersede the declaration. If a patient is
incompetent, the declaration will be presumed to be valid.
The Kansas Natural Death Act imposes duties on physicians and provides penalties for violations of
the laws about declarations.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-18
8400. Updated 11/03
The Kansas Durable Power of Attorney for Health Care Decisions Law, K.S.A. 58-625,
et seq.
A "durable power of attorney for health care decisions" is a written document in
which an adult gives another adult (called an "agent") the right to make health care
decisions. The power of attorney applies to health care decisions even when the adult
is not in a terminal condition. The adult may give the agent the power to:
1.
Consent or to refuse consent to medical treatment;
2.
Make decisions about donating organs, autopsies, and disposition of the body;
3.
Make arrangements for hospital, nursing home, or hospice care;
4.
Hire or fire physicians and other health care professionals; or
5.
Sign releases and receive any information about the adult.
A "durable power of attorney for health care decisions" may give the agent all those
five powers or may choose only some of the powers. The power of attorney may not
give the agent the power to revoke the adult's declaration under the Kansas Natural
Death Act ("living will"). The power of attorney only takes effect when the adult is
disabled unless the adult specifies that the power of attorney should take effect earlier.
The adult may not make a health care provider treating the adult the agent except in
limited circumstances.
The power of attorney may be made by two methods:
1.
In writing;
2.
Signed by the adult making the declaration;
3.
Dated;
4.
Signed in front of two adult witnesses;
Or:
Written and notarized.
Relatives by blood or marriage, heirs, or people who are responsible for paying for
the medical care may not serve as witnesses.
The adult, at the time the power of attorney is written, should specify how the power of attorney may
be revoked.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-19
8400. Updated 10/09
The Patient Self-Determination Act, Section 1902(w) of the Social Security Act
This federal law, codified at 42 U.S.C. Sec. 1396a(w), was effective December 1, 1991. It applies to
all Medicaid and Medicare hospitals, nursing facilities, home health agencies, hospices, and prepaid
health care organizations. It requires these organizations to take certain actions about a patient's right
to decide about health care and to make advance directives.
This law also required that each state develop a written description of the State law about advance
directives. This description was written by the Health Care Policy Section of the Kansas Department
of Social and Rehabilitation Services (SRS) to comply with that requirement. If you have any
questions about your rights to decide about health care and to make advance directives, please consult
with your physician or attorney.
Third Edition: January 14, 2003
Abortions
Abortions are covered only under the following conditions:
• In the case where a woman suffers from a physical disorder, physical injury, or physical
illness, including a life-endangering physical condition caused by or arising from the
pregnancy itself
• If the pregnancy is the result of an act of rape or incest
The physician must complete the Abortion Necessity Form to certify that the woman's
physical health is in danger or that the pregnancy is a result of rape or incest. The form,
located on the public and secure websites (see the Table of Contents for hyperlinks) at the end
of this manual in the Forms section, Abortion Necessity Form, or on the provider Web site
under Publications, Forms, Abortion Necessity Form, may be photocopied for your use. All
blanks must be completed, including the patient's complete address.
Claims submitted for abortions due to rape or incest must be accompanied by a statement
signed by the physician stating that he or she was informed by the patient that the pregnancy
was the result of rape or incest. No further documentation is required to process the claim.
However, all pertinent information must be retained with the medical record.
Children and Family Services (CFS) Contractors
Medicaid reimbursable services will not be paid by child welfare contractors. All services for
children assigned to contractors, including behavior management and mental health, must be
billed directly to KMAP and will be reimbursed at the approved Medicaid rate. Prior
authorization (PA) and other restrictions apply.
Bone Anchored Hearing Aid
Effective with dates of service on and after March 1, 2009, aA bone anchored hearing aid
(BAHA) is covered by KMAP with the following specifications and limitations. A BAHA is
limited to one every four years, with one replacement. PA is required for all BAHA services.
All providers must obtain a PA prior to providing service.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-20
8400. Updated 02/09
Bone Anchored Hearing Aid (continued)
A BAHA is covered with PA for a KAN Be Healthy (KBH) beneficiary who meets all of the
following criteria:
• Each of items one, two, three and four
• Either items five or six
• At least one of items seven, eight or nine
1. The beneficiary must be five years of age or older.
2. Standard hearing aids cannot be used due to a medical condition.
3. The beneficiary has adequate manual dexterity or the assistance necessary to snap the
device onto the abutment.
4. The beneficiary has the ability to maintain proper hygiene at the site of the fixture.
5. Tumors of the external canal and/or tympanic cavity are present.
6. Congenital or surgically induced malformations (e.g., atresia) of the external ear canal
or middle ear are present.
7. There is unilateral conductive or mixed hearing loss.
8. There is bilateral conductive hearing loss.
9. There is unilateral sensorineural hearing loss (single-sided deafness).
Definitions
• Unilateral conductive or mixed hearing loss: Unilateral conductive or mixed hearing
loss caused by congenital malformations of the external or middle ear. Conventional
hearing aids cannot be worn. Beneficiary must have:
o Average bone conduction threshold better (less) than 45 dB (at 500, 1000, 2000, 3000
Hz) in the indicated ear
o Speech discrimination score greater than 60 percent in the indicated ear
• Bilateral conductive hearing loss: Conductive and mixed hearing loss involving both ears
which is not able to be treated with reconstructive surgery or conventional hearing aids.
Beneficiary must meet all of the following:
o Moderate (40dB) to severe (70dB) conductive hearing loss symmetrically
o Less than 10dB difference in average bone conduction (at 500, 1000, 2000, 4000 Hz)
or less than 15 dB difference in bone conduction at individual frequencies
o Mixed hearing loss with an average bone conduction better (less) than 45dB in either
ear (at 500, 1000, 2000, 4000 Hz)
• Unilateral sensorineural hearing loss (single-sided deafness): Nerve deafness in the
indicated ear making conventional hearing aids no longer useful. The implant is designed
to stimulate the opposite (good ear) by bone conduction through the bones of the skull.
Therefore, the audiometric criteria are for the good ear. Beneficiary must meet all of the
following:
o Severe (70dB) to profound (90dB) hearing loss on one side with poor speech
discrimination and the inability to use a conventional hearing aid in that ear
o Normal hearing in the good ear as defined by an air conduction threshold equal to or
better (less) than 20dB (at 500, 1000, 2000, 3000 Hz)
A child younger than five years of age with unilateral congenital atresia of the ear canal or
middle ear in the presence of a maximum conductive hearing loss and adequate cochlear
(inner ear) function may be considered on an individual basis. Adequate cochlear function is
demonstrated audiologically when stimulation through bone conduction results in significantly
improved and functional hearing in the involved ear.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-21
8400. Updated 11/09
Bone Anchored Hearing Aid (continued)
For a child with congenital malformations, sufficient bone volume and bone quality must be
present for a successful fixture implantation. Alternative treatments, such as a conventional
bone conduction hearing aid, should be considered for a child with a disease state that might
jeopardize osseointegration.
Replacements
• One replacement BAHA is covered for a KBH beneficiary who meets the initial
placement criteria.
• PA is required for all BAHA replacement services. All providers must obtain a PA prior
to providing service.
• A replacement processor cannot be billed at the same time as the original processor or the
original surgery.
• Replacements are limited to one every four years if lost, stolen, or broken.
• A replacement is not allowed for the purpose of upgrading. A BAHA can only be
replaced if the current processor has an expired warranty, is malfunctioning, and cannot
be repaired.
Immunization/Vaccine
Reimbursement for covered immunizations for children is limited to the administration of the
vaccine only. Vaccines are supplied at no cost to the provider through Vaccines for Children,
a federal program administered by KDHE.
Codes 90470 and G9141 are covered for the administration of the H1N1 vaccine. These codes
are covered for all benefit plans, except for beneficiaries who only have ADAPD coverage,
with a reimbursement rate of $14.15. Claims for the administration of the H1N1 vaccine
should be billed with diagnosis code V04.81 (H1N1). Since the H1N1 vaccine is available at
no cost to providers, payment is not being issued for 90663 or G9142. If providers are
interested in administering the H1N1 vaccine, they can contact KDHE to receive the vaccine.
Intrathecal Baclofen Pump
Intrathecal baclofen pumps are covered for Medicaid beneficiaries. This includes the initial
and all subsequent implantation(s), revision(s), repairs, catheters, batteries, refills, removals,
and maintenance of the intrathecal baclofen pumps when indicated. Three services require
PA: 62350, 62351, and 62362. The following conditions must be met:
• The beneficiary must have responded favorably to a trial of intrathecal baclofen and
documentation of previously used medication
•
The beneficiary’s ICD – diagnosis code must be a covered code and the source of the
spasticity must be documented
•
The beneficiary must be over the age of four years or there must be documentation that
there is sufficient space within the child’s chest wall for the pump to be implanted.
•
Contraindications include pregnancy and active infection at time of surgery
Procedure codes 62311, 62319, 62355, 62365, 95990, 95991, and 62368 do not require PA,
but HealthConnect beneficiaries do need a referral from their PCPs.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-22
8400. Updated 11/09
Renal Dialysis and Kidney Transplant
When it has been determined a beneficiary has chronic renal disease (CRD) requiring renal
dialysis, the beneficiary or his representative should apply for Medicare CRD eligibility.
Renal Dialysis and Kidney Transplant (continued)
Medicare allows for payment of claims for eligible beneficiaries with chronic renal disease
and will reimburse for maintenance dialysis the third month after the maintenance dialysis
starts. Medicare will reimburse for maintenance dialysis in the first three months if the
beneficiary has been involved in self training in a self-care dialysis unit or through a self-care
home dialysis support service provided by a qualified provider. They also reimburse for
expenses incurred for a kidney transplant including those for the kidney donor.
Medicaid will reimburse claims for services related to chronic renal dialysis and/or kidney
transplants only after proof has been attached to one claim that the beneficiary has applied for
Medicare and coverage has been approved or denied. The Medicare CRD eligibility
information will be retained in the claims processing system. Therefore, subsequent claims do
not need to have proof of Medicare CRD eligibility approval or denial attached.
Acceptable proof of application and coverage or denial by Medicare are:
• Medicare EOMB/RA
• Beneficiary health insurance card
• Report of Confidential Social Security Benefit Information
• Letter from Medicare or Social Security explaining that the beneficiary has applied for
Medicare and whether beneficiary is eligible
Hospitals Qualifying For Federal Renal Program *Approved for dialysis only
Univ. of Kansas Med. Center
St. Francis Regional Med. Center
39th & Rainbow Boulevard
929 North St. Francis
Kansas City, Kansas 66103
Wichita, Kansas 67211
St. Luke's Hospital
44th and Wornall Road
Kansas City, Missouri 64111
Research Hospital & Medical Ctr.
Meyer Boulevard & Prospect
Kansas City, Missouri 64132
St. Francis Hosp. & Health Center*
1700 West Seventh Street
Topeka, Kansas 66606
Children's Mercy Hospital
24th at Gillham Road
Kansas City, Missouri 64108
(CAPD Training & Support Services)
Kansas City Dialysis & Training
Center*
Located at Research Hospital
Meyer Boulevard & Prospect
Kansas City, Missouri 64132
Salina Regional Health Center
400 S. Santa Fe
Salina, Kansas 67406
FOR VETERANS
Kansas City V.A. Hospital
4801 Linwood Boulevard
Kansas City, Missouri 64128
Wichita V.A. Hospital
5500 East Kellogg
Wichita, Kansas 67218
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-23
8400. Updated 10/09
Surgery - Ambulatory/Outpatient
Ambulatory surgery centers and outpatient hospitals will be reimbursed for multiple unrelated
outpatient surgical procedures performed on the same day as follows: 100 percent of the
current Medicaid rate for the highest value procedure; 50 percent of the current Medicaid rate
for the second procedure; and 25 percent of the current Medicaid rate for all subsequent
procedures.
IVs, medications, supplies and injections provided on the same day as an
ambulatory/outpatient surgery procedure are considered content of service of the surgery and
cannot be billed separately. EXCEPTION: The following thrombolytic enzymes are not
considered content of service when billed in conjunction with outpatient surgery: J2997,
J2993, J3364, J2995 and J0350.
Anesthesia (equipment and supplies), drugs, surgical supplies and other equipment of the
operating room and the recovery room are considered content of service of the
ambulatory/outpatient surgical procedure.
Surgery - Breast Reconstruction
Breast reconstruction is covered when the beneficiary had a mastectomy for breast cancer on
or after March 1, 2005. Only the breast reconstruction procedure codes listed in Appendix II
are covered. Only the following breast reconstruction codes are covered. For the most current
information and verification of coverage, access Reference Codes under the Provider tab on
the public website at https://www.kmap-state-ks.us/Provider/PRICING/RefCode.asp
or from the secure website at https://www.kmap-state-ks.us/provider/security/logon.asp.
Outpatient Codes
Physician Codes
11970
11971
11970
11971
19316
19316
19340
19340
19342
19350
19342
19350
19357
19361
19364
19357
19366
19366
19367
19368
19369
69990
This coverage is limited to one breast reconstruction process per breast per lifetime.
Surgery - Cosmetic
All surgeries which are cosmetic in nature (and related complications) are not covered. Any
medically necessary procedure which could ever be considered cosmetic in nature must
receive PA. The hospital must have a copy of the physician's PA for claim processing
purposes.
Surgery - Elective
The Medicaid program will not reimburse for inpatient/outpatient elective surgery unless the
beneficiary is a KBH participant.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-24
8400. Updated 10/09
Certain surgical procedures will be reviewed on a postpay random sample basis by the KHPA
physician. Retain all documentation supporting the nonelective nature of the surgery for
review. Supporting documentation includes admission notes/history and physical, operative
report and pathology report. If the documentation does not support the nonelective nature of
the surgery, reimbursement for all claims relating to the surgery will be recovered.
Therapy
Therapy treatments are not covered for a psychiatric diagnosis.
Habilitative - Therapy is covered for any birth defects/developmental delays only when
approved and provided by an Early Childhood Intervention (ECI), Head Start or Local
Education Agency (LEA) program. Therapy treatments performed in the LEA settings may be
habilitative or rehabilitative for disabilities due to birth defects or physical trauma/illness.
Therapy of this type is covered only for beneficiaries zero to under 21 years of age. Therapy
must be medically necessary. The purpose of this therapy is to maintain maximum possible
functioning for children.
Rehabilitative - All therapies must be physically rehabilitative. Therapies are covered only
when rehabilitative in nature and provided following physical debilitation due to an acute
physical trauma or physical illness and prescribed by the attending physician.
Therapy services are limited to six months for non-KBH participants (except the provision of
therapy under HCBS), per injury, to begin at the discretion of the provider. There is no
limitation for KBH participants.
Providers of rehabilitative therapy can submit claims with a combination of the following
rehabilitation therapy procedure codes and a diagnosis code in the range of V57.0-V57.9 as
the primary diagnosis. Providers are required to submit a secondary diagnosis code to
describe the origin of the impairment for which rehabilitative therapy is needed when one of
these V-codes is billed as a primary diagnosis.
97001
97003
97010
97012
97014
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97110
97112
97113
97116
97124
97140
97150
97530
97535
97750
Transplants
Liver transplants for Medicaid beneficiaries will only be reimbursed at the University of
Kansas Medical Center or at a hospital recommended by their staff.
Heart, lung, and heart/lung transplants performed in approved in-state or border city hospitals
are covered for KBH participants only.
Bone marrow, cornea, kidney, and pancreas transplants performed in approved in-state or
border city hospitals are covered and do not require PA.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-25
8400. Updated 10/09
Pancreas transplants are only covered when performed simultaneously with or following a
kidney transplant.
Tuberculosis
Inpatient services related to a tuberculosis (TB) diagnosis, including physician and laboratory
services, are covered for beneficiaries with the TB benefit plan.
Inpatient hospitalization, including physicians’ services for diagnostic evaluation of
beneficiaries highly suspected of TB, is covered for completion of the diagnosis.
Acute problems, which are present on admission or arise during hospitalization, are covered
services. Hospitalization for monitoring toxicity of anti-tuberculosis drugs is covered.
Inpatient claims may be billed directly to KMAP.
Coverage and payment of inpatient or outpatient services are subject to compliance with
infectious disease reporting requirements as directed by K.A.R. 28-1-2.
Coverage and payment of outpatient services are coordinated between KDHE and KHPA in
accordance with the current interagency agreement. Contact KDHE at 785-296-0739 for
determination of coverage.
Anti-tuberculosis drugs to treat the beneficiary and family members are provided at no cost by
KDHE. Contact your local health department or KDHE at 785-296-2547.
Vagal Nerve Stimulators
Vagal nerve stimulators (VNS) are covered for beneficiaries with epileptic disorders. With the
exception of procedure codes 95970 and 95974, all services must be prior authorized.
VNS services must meet the following conditions:
• The beneficiary must have an epileptic disorder. VNS will not be covered for
beneficiaries with previous epileptic brain surgery or beneficiaries with progressive
disorders.
• Mental retardation with epilepsy is not a contraindication for VNS but must be
considered with other factors.
• All other courses of treatment must be documented, such as conventional and
anti-convulsant drugs.
• There is no age restriction. The beneficiary’s physicians are expected to determine
whether or not VNS surgery is appropriate and to document those findings in the
medical record.
• Providers are expected to maintain adequate documentation, such as “decreased
seizure activity” or “improvement in seizure condition.”
Refer to Appendix II for a list of covered codes.
Vacuum Assisted Wound Closure Therapy
Vacuum assisted wound closure therapy is covered for specific benefit plans. PA is required
and criteria must be met. Refer to the DME Provider Manual for criteria. For questions about
service coverage for a given benefit plan, contact the KMAP Customer Service Center at
1-800-933-6593 or 785-274-5990. All PA must be requested in writing by a KMAP DME
provider. All medical documentation must be submitted to the KMAP DME provider.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-26
BENEFITS AND LIMITATIONS
8410. MEDICAID - INPATIENT ONLY Updated 02/09
General Hospital Reimbursement Policies
Payment for general inpatient hospital services is based on the following equation: DRG
weight times (X) group payment rate plus (+) outlier costs, if appropriate.
Medicaid does not reimburse for days not medically necessary or deemed "not payable" by
federal or state laws, regulations, or state policy.
All DRGs have the potential for day or cost outliers.
When a stay is eligible for both day and cost outliers, the greater of the two is paid.
Only day outlier payment is made for hospitalization extending beyond 360 days.
If a Medicaid beneficiary is transferred from one hospital to another, the transferring hospital
will receive outlier payments when the length of stay is greater than the DRG day or cost
outlier. The hospital billing the final discharge receives the standard DRG payment including
outliers, if applicable.
When a Medicaid beneficiary is discharged prematurely and subsequently readmitted within
30 days, only the DRG payment for the first stay will be made if the discharging and
readmitting hospital are the same. If the discharging and readmitting hospitals are not the
same, only the readmitting hospital will be reimbursed.
When the Medicaid beneficiary is not eligible for the entire inpatient stay, the DRG payment
is prorated and reimbursement is made only for the days the beneficiary was eligible.
Reimbursement shall not exceed the standard DRG payment plus any applicable outlier
payment. (Only covered days are used to calculate outliers.)
Hospitals can issue a continued stay denial to a beneficiary only after the attending physician
has written a discharge order. The hospital must supply the beneficiary with the necessary
notification that the beneficiary will assume responsibility for payment since a continued stay
is not considered medically necessary and is no longer a covered service.
Admissions or day outliers found to be unnecessary by the utilization review contractor cannot
be billed to the beneficiary.
KANSAS MEDICAL ASSISTANCE PROGRAM
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Dental Admissions
Dental admissions are covered when medically necessary. Documentation supporting the
medical or dental condition making hospitalization necessary must be in the medical record.
PA is required for adults. Medical review is required for children 21 years of age and under.
Claims for this service are to be billed with procedure code 41899 and must include a detailed
description of the actual service provided.
Emergency Renal Dialysis
Emergency renal dialysis (revenue code 809) is only allowed once in an 18-month period per
beneficiary.
State Institutions for Mental Health
State institution services are only covered for Medicaid beneficiaries under 21 years of age or
65 years of age and older. (However, if a beneficiary is an inpatient in a state institution on
their 21st birthday, state institution services will be covered until the 22 years of age.)
State institutions are reimbursed 100 percent of the amount billed.
Long-Term Care Units
Long-term care units must be a distinct or separate unit of a hospital certified to provide
skilled and/or intermediate care under KMAP subject to the same federal and state rules and
regulations as a free-standing adult care home. This includes compliance with federal
regulations for standards of care and related reimbursement.
Noncovered Services
• Take home drugs
•
Nonmedical hospital supplies (e.g., hospital kits)
Psychiatric
A psychiatric preadmission assessment is not required for inpatient medical treatment when
the admission was the result of a medical manifestation of a psychiatric disorder and the
beneficiary was not admitted to the psychiatric unit.
Inpatient general hospital psychiatric admissions are covered only after a psychiatric
preadmission assessment has been completed and a determination made that the most
appropriate treatment setting is the hospital. [As required by Mental Health Reform,
community mental health centers (CMHCs) review all admissions to state hospitals.] No
payment will be made for the hospital admission or related physician services without the
completion of the preadmission assessment and determination that the hospital admission
meets criteria. When seeking to admit a KMAP beneficiary for inpatient treatment call
1-800-466-2222 to arrange for the assessment to be completed. This toll-free number is
staffed 24 hours a day by the Mental Health Consortium (MHC).
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Psychiatric (continued)
All individuals, determined by the hospital, to be potentially eligible for KMAP benefits must
have a psychiatric preadmission assessment performed prior to admission into an acute care
general or special hospital. The following criteria is a guideline that should assist hospitals in
determining which individuals are potential candidates for KMAP benefits:
• Individuals receiving supplemental security income (SSI) or have applied for SSI
• Individuals on Social Security
• Individuals who have been unemployed longer than six months
• Individuals who have applied or will be applying for KMAP
After receiving a request for a psychiatric preadmission assessment, the MHC will contact the
appropriate CMHC, or other approved provider if the admission is out of state, to complete
the assessment face-to-face with the patient. The hospital and admitting physician will be
notified of the results verbally and through a letter from the MHC. If the admission is
approved a PA number will be included in the letter for the hospital to use when billing for
the admission and related services.
A referral from the beneficiary's primary care provider is not required for a psychiatric
hospital stay or related physician and ancillary services provided during the psychiatric
hospitalization approved through the preadmission assessment process.
Free Standing Psychiatric Hospitals
Federal regulations classify free standing psychiatric hospitals as institutions for mental
disease (IMDs). Medicaid reimbursement to IMDs is restricted to treatment of beneficiaries
20 years of age and younger or 65 and older. Even though an admission may be authorized
by a preadmission screening, Medicaid reimbursement to free standing psychiatric hospital
providers (with a specialty of 011 B3) will be made only for beneficiaries under 21 years of
age or 65 and older at admission.
Emergency Psychiatric
Screening for inpatient services following the sudden onset of severe psychiatric symptoms,
which could reasonably be expected to make the individual harmful to self or others if not
immediately under psychiatric care. The individual is in crisis and not currently in a place of
safety. A screening is completed immediately (no later than three hours) to determine
appropriate placement.
Urgent Psychiatric
Screening is initiated if the individual meets one of the four independent criteria and is
currently in a place of safety. An observation bed may be used to provide security and
“observation” for individuals in imminent danger and to assist in the determination of the
need for psychiatric hospitalization. In this instance, the screening must be completed as soon
as possible and within two days of the consortium’s receipt of the request.
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Planned Psychiatric
Noncrisis in nature, the screening must be completed within two days of the consortium’s
receipt of the request. The admission must occur within two days of the completion of the
screening.
Retroactive Psychiatric
Individuals whose Medicare or other primary insurance denied payment for treatment and who
were Medicaid eligible at the time of admission. Other retroactive screens may be authorized
for denied requests when eligibility is in question. If the individual receives a valid Medicaid
card after a hospital admission has been completed, the consortium requests the admission
information, and completes a preadmission screening within five working days of the receipt
of that information.
Cases Involving Retroactive Eligibility
The assessment must be requested and completed prior to the admission and related services
being billed to Medicaid. The assessment will not be face-to-face and will be completed by
the MHC. The MHC must complete the assessment within five working days of receiving
the request.
Cases Involving Other Insurance or Medicare
If the admission and related services are billed to other insurance or Medicare first, the
psychiatric preadmission assessment is not necessary. If the other insurance or Medicare
makes no payment on the claim, prior to the claim being billed to Medicaid, an assessment
must be completed. The MHC will complete the assessment within five working days of
receiving the request. The assessment will not be face-to-face.
A face-to-face psychiatric preadmission assessment consists of a psychiatric diagnostic
interview examination including history, mental status examination, and communication with
family members and other collateral contacts in order to develop an appropriate treatment
plan.
Placement problems for children in SRS custody: The SRS office suggests that efforts to make
arrangements for placement in a state hospital or appropriate long-term care facility should
begin as soon as the need for prolonged nonacute inpatient care becomes apparent. The local
SRS office, the physician, or the hospital should contact Adult and Medical Services for
assistance in placement, if necessary. Please request this assistance by the 6-10th day of stay
in an acute hospital.
Substance Abuse
Acute detoxification is covered in any acute general hospital, when medically necessary.
Alcohol and drug addiction treatment services provided in an inpatient hospital setting are not
covered.
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Utilization Review General Hospitals
Utilization review (UR) is performed on a postpayment basis for general hospitals with the
exception of some readmissions, some interim bills and some adjustments. (URs are
performed internally at state institutions.)
Review of outlier cases are conducted on all cases with day or cost outliers. Reviews are
performed on a postpay basis, unless interim bills are submitted and the beneficiary is still an
inpatient.
Readmissions within 30 days of a discharge are reviewed on a postpayment basis.
All patient initiated transfers are subject to UR.
When a patient is transferred from an inpatient hospital bed to a swing-bed unit and acute care
continues to be provided, payment for the swing-bed will be denied or recouped. The only
purpose for this type of transfer is for the hospital to obtain reimbursement beyond the DRG
payment.
Following DRG coding evaluation and adjustment by the UR contractor, payment of claims
will be adjusted upward or downward. In this instance, the fiscal agent will initiate the
adjustment.
When a hospital admission is determined to be nonmedically necessary by the Medicaid
utilization review contractor (KFMC), resulting in recoupment of payment, the provider shall
not rebill the claim as an outpatient service.
UR may be performed either on-site or by reviewing records sent as required to the UR
contractor. If a hospital fails to provide the UR contractor with the complete requested
information within the allowable time frames, the case will be denied, resulting in recoupment
of payment. These "technical denials" are not eligible for reconsideration. If the facility
supplies the UR contractor the information within 90 days of the "technical denial" date, the
case may be reopened for review. Pending the review results, repayment for the case may
occur.
Discharge Day Not Medically Necessary
When a beneficiary's hospital discharge day is determined by the UR contractor to not be
medically necessary, the discharge day is redefined as the last medically necessary day. This
redefined discharge day is not reimbursed.
KANSAS MEDICAL ASSISTANCE PROGRAM
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BENEFITS & LIMITATIONS
8-31
BENEFITS AND LIMITATIONS
8420. MEDICAID - OUTPATIENT ONLY Updated 10/09
Emergency Medical Services for Aliens (SOBRA)
In addition to inpatient hospital and emergency room hospital, emergency services performed
in outpatient facilities and related physician, lab, and X-ray services will be allowed for the
following places of service: office, outpatient hospital, Federally Qualified Health Clinics,
state or local public health clinics, Rural Health Clinics, ambulance, and lab for SOBRA
claims. Inpatient hospital reimbursement will not be limited to 48 hours. Follow-up care will
not be allowed once the emergent condition has been stabilized.
Refer to Section 2040 of the General Benefits Provider Manual for specific information.
Blood
Blood transfusions, including whole blood, red blood cells, plasma, platelets and
cryoprecipitate, and IV infusions are covered services.
Set-ups including volume controller cassettes are content of service of the procedure billed.
Crisis Resolution Services
Hospitals may be reimbursed when Medicaid patients are admitted to observation/stabilization
beds for crisis resolution services in accordance with the following conditions:
• There is an affiliation agreement between the admitting hospital and the licensed
community mental health center.
• The patient must be referred by the primary care case manager, agency, or health
professional currently providing care (whichever is applicable).
• The patient shall have demonstrated an acute change in mood or thought that is
reflected in behavior, indicating the need for crisis intervention to stabilize and
prevent hospitalization.
• The patient must have a diagnosed psychiatric disorder.
• The patient must not be in need of acute detoxification or experiencing withdrawal
symptoms.
• The patient must be medically stable.
• The following documentation must be completed:
o Nursing assessment (including physical review, mental status, and medication)
o Strength assessment
o Personal crisis plan
o At least one progress note
Crisis resolution services are covered up to two consecutive days and must be billed under
procedure code H2013.
Developmental Testing
Providers are reimbursed one visit per day, up to three visits per beneficiary per year, for
code 96111.
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Diagnostic Tests
Although not all HCPCS codes are covered, most procedure codes for laboratory, radiology,
EKG, EEG, hearing and speech testing (if provided following physical debilitation)
are covered.
Drugs
All drugs are content of service of surgery. Oral drugs are content of service of emergency
treatment. Take-home drugs are noncovered.
Injections, IVs, blood infusions, and aerosol inhalant additives are covered if not associated
with surgery.
Electro-Convulsive Treatments
Electro-convulsive treatments are covered and include all ancillary services needed to provide
the treatment, including the charge for use of a bed.
Emergency Room Services
Emergency room (ER) encounters will not deny based on ICD-9 diagnosis codes.
Nonemergent claims will be reduced to the 99281 rate.
Medical necessity documentation must accompany the claim when more than one ER visit is
made on the same day for the same individual.
The ER visit is content of service to any surgical and therapeutic treatment procedures
performed in an emergency room.
Laboratory
Handling fee (drawing/collection) is considered content of service of the outpatient visit/lab
procedure and is not covered if billed separately. The beneficiary cannot be billed for the
drawing or collection since it is considered content of another service or procedure.
Laboratory procedures performed on inpatients are content of service of the DRG
reimbursement to the hospital and should not be billed by either the independent laboratory
or hospital.
Pathologists not contracted by the hospital may bill modifier 26 for pathology services
provided on inpatients.
Reimbursement will only be made for one complete blood count (CBC) per day.
Only the provider performing the laboratory analysis can bill.
When ordered laboratory tests make up a panel or profile, the all-inclusive procedure code
should be used to bill. Components should not be billed separately.
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Laboratory (continued)
Three or more multichannel tests are considered a SMA/SMAC profile when performed on
the same date of service. Medicaid follows the guidelines outlined in the CPT® codebook to
identify automated multichannel tests (SMACs, profiles) performed. When billing for a
multichannel test use the appropriate CPT® procedure code (80002-80019).
Urinalysis (UA) is considered content of service of the reimbursement to the physician for
antepartum care when the UA is obtained for a diagnosis of pregnancy. The
hospital/independent laboratory will not be reimbursed by Medicaid for the UA in
this situation.
Cytogenetic (chromosome) studies are covered for pregnant women (when medically
necessary) and KBH participants only. A medical necessity form must accompany the claim
when billing for a cytogenetic study for a pregnant woman older than 21 years of age.
The following HIV testing is limited to four per calendar year, regardless of provider. Refer
to the CPT® codebook for complete descriptions of these procedures: 86689, 86701, 86702,
86703, 87390, 87391, 87534, 87535, 87537, 87538, 87539, 87900, 87903, 87904.
• Code 87536 is covered.
• Code 87901 is covered. Medical necessity documentation must include information
that the patient meets at least one of the following criteria:
1. The patient presents with virologic failure during Highly Active Antiretroviral
Therapy (HAART).
2. The patient has suboptimal suppression of viral load after initiation of
antiretroviral therapy.
Note: For 87901 only, testing is limited to two per calendar year.
Life Sustaining Therapy
Chemotherapy, radiation therapy and renal dialysis are covered.
Noncovered Services
Medical supplies used in conjunction with outpatient surgery and/or the emergency
room/observation room are considered content of service and cannot be billed separately.
The rental or sale of DME and certain prosthetic and orthotic items are not covered.
Operating Room
Anesthesia (equipment and supplies), drugs, surgical supplies and other equipment of the
operating room, the recovery room and supplies are considered content of service of the
operating and/or delivery room charges.
Outpatient Procedures
Outpatient services provided within three days of an admission from the same hospital for the
same or similar diagnosis are considered content of service of the inpatient hospital stay. In
this instance, bill the outpatient charges together on the inpatient claim.
There is one exception to this policy, complications from an outpatient sterilization resulting
in an inpatient admission. In this instance, the outpatient charges and the inpatient charges
should be billed on two separate claims.
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HealthConnect/Managed Care Documentation
Acceptable outpatient hospital referral documentation includes an entry in the hospital
outpatient or emergency department medical record noting that the primary care provider
(PCP) was contacted at the time the service was rendered and approval was given. The
statement must be signed by the individual who received the approval. If the PCP cannot be
reached, approval must be secured from one of his or her covering physicians.
Prosthetic & Orthotic Services
Outpatient hospitals will be allowed to bill the following prosthetic & orthotic codes:
L3700
L3720
L3845
L3906
L3907
L3908
L3912
L3914
L3916
L3918
L3928
L3930
L3934
L3938
L3942
L3948
L3954
L3980
DeFlux, an injectable medical device, is covered with PA. Use procedure code L8606.
Psychiatric Observation Beds
Psychiatric observation beds are covered up to two consecutive days. During the observation
period the patient must receive:
• A physical examination
• History and psychiatric assessment containing recommendations for ongoing treatment
• An initial nursing assessment
• Nursing progress notes written each shift
• A discharge summary
A physician must admit the patient to an observation bed and discharge him or her at the end
of the observation stay. When an admission follows an observation stay, the physical
examination report and the psychiatric assessment must be included in the patient's medical
record. The observation bed stay becomes part of the DRG payment to the hospital. Refer to
Section 7020 for billing instructions.
Psychiatric Partial Hospitalization
These services are covered only in those hospitals where such a program has been approved
by SRS.
KANSAS MEDICAL ASSISTANCE PROGRAM
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BENEFITS & LIMITATIONS
8-35
8430. FAMILY PLANNING/STERILIZATIONS Updated 10/09
Family Planning
Family planning is any medically approved treatment, counseling, drugs, supplies, or devices
which are prescribed or furnished by a provider to individuals of child-bearing age for
purposes of enabling such individuals to freely determine the number and spacing of
their children.
Insertion or removal of an implantable contraceptive requires medical necessity documentation
when performed in an outpatient setting.
Complete the family planning block on the claim form whenever a procedure or service is
performed which relates to family planning.
The following information is provided to facilitate coding the FL 18-28 of the UB-04 claim
form. The two-digit indicator A4 is to be placed in this field.
The following procedures are family-planning related. The Sterilization Consent Form must
be attached to the surgeon's claim at the time of submission. Related claims (anesthesia,
assistant surgeon, ambulatory surgery center, hospital or rural health clinic) do not require an
attached Sterilization Consent Form. However, if not attached, processing will be delayed
until the consent form with the surgeon's claim is reviewed and determined to be correct.
ICD-9-CM Procedure Code (IP) and Code
IP
Code
IP
Code
IP
Code
IP
Code
63.70-.73
55250
66.39
58600
V25.2
58661
66.20-.21
58670
55450
66.92
58605
66.29
58671
66.31-.32
66.39
66.92
Sterilizations
Hysterectomy
Hysterectomies are covered only for medically indicated reasons. Medicaid will reimburse for
this service only if at least one of the following three conditions is met and documented.
1. The individual or her representative signs the Hysterectomy Necessity Form
acknowledging receipt of information that the surgery will make her permanently
incapable of reproducing. The Sterilization Consent Form is not an acceptable
substitute.
2. The physician shall certify in writing that the individual was already sterile and state
the cause or reason for the sterility on an attachment to the claim.
3. For the Sterilization Consent Form only, the physician shall certify in writing that the
surgery was performed under a life-threatening situation and individual certification
was not possible, including a description of the nature of the emergency.
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8430. Updated 10/09
A copy of the Hysterectomy Necessity Form must be attached to the surgeon's claim at the
time of submission. The form is located on the public and secure websites (see the Table of
Contents for hyperlinks) at the end of this manual in the Forms section or on the KMAP Web
site under Publications, Forms, Hysterectomy Necessity Form. It may be photocopied for
your use. A copy of the Hysterectomy Necessity Form does not have to be attached to related
claims (anesthesia, assistant surgeon, hospital, or rural health clinic) at the time of
submission. However, a related claim will not be paid until the Hysterectomy Necessity
Form with the surgeon's claim has been reviewed and determined to be correct, unless
the related claim has the correct Hysterectomy Necessity Form attached.
All Sterilizations
Guidelines
Sterilizations on mentally incompetent individuals or individuals institutionalized for mental
illness are not covered.
The following guidelines must be accurately followed before reimbursement can be made for
any sterilization procedure (including, but not limited to, hysterectomy, tubal ligation
sterilization, and vasectomy). If each item is not followed completely, it will result in the
denial of your claim. KHPA KMAP or other authorized agencies may ask for documentation
at any time, either during the claims processing period or after payment of a claim, to verify
that services have been provided within program guidelines.
1. The Sterilization Consent Form, mandated by federal regulation, is located on the
public and secure websites (see the Table of Contents for hyperlinks) at the end of this
manual in the Forms section or on the KMAP Web site under Publication, Forms,
Sterilization Consent Form. Instruction on how to complete the Sterilization Consent
Form is posted following the forms. Providers may photocopy this form. All voluntary
sterilization claims submitted without this specific Sterilization Consent Form will be
denied. All fields must be completed, including the physician signature.
2. The Sterilization Consent Form must be signed so that 30 days have passed before the
date the sterilization is performed with the following exceptions:
Premature Delivery
• The date of the beneficiary’s consent must be at least three calendar days prior to
the date the sterilization was performed.
• The expected date of delivery must be indicated on the consent form and the date
of the beneficiary’s consent must be at least 30 days prior to the expected date of
delivery.
Emergency Abdominal Surgery
• The date of the beneficiary’s consent must be at least three calendar days prior to
the date the sterilization was performed.
• The circumstances of the emergency abdominal surgery must be described by the
physician sufficiently to substantiate the waiver of the 30-day requirement.
Note: Three calendar days is used in the above exceptions to guarantee compliance
with the minimum federal requirement of 72 hours.
3. The Sterilization Consent Form is valid for 180 days from the date it is signed by the
beneficiary. Sterilization claims for individuals that reflect dates of service beyond 180
days from the date the consent form was signed will be denied.
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4. The individual must be at least 21 years of age or older on the date the consent form is
signed, or the sterilization claim will be denied. (This includes those situations in
which the individual has misrepresented his or her age on the consent form to the
provider.) The birth date information provided by SRS will be used to determine
whether the individual meets the age requirement. This information can be obtained
through KMAP Customer Service.
5. Sterilizations on mentally incompetent individuals are not covered. "Mentally
incompetent individual" is defined as an individual who has been declared mentally
incompetent by a federal, state or local court of competent jurisdiction for any purpose,
unless the individual has been declared competent for purposes which include the
ability to consent to sterilizations" (42 CFR 441.251).
6. The sterilization is not covered when consent is obtained from anyone in "labor,"
under the influence of alcohol or other drugs, or seeking or obtaining an abortion.
7. Interpreters must be provided when there are language barriers, and special
arrangements must be made for handicapped individuals.
8. The physician's statement must be signed and dated no more than two days prior to the
surgery, the day of the surgery, or any day after sterilization was performed. If this
field is left blank, your claim will be denied.
9. The physician statement on the consent form must be signed by the physician who
performed the sterilization. No other signatures will be accepted.
When sterilization results from the treatment of a medical condition, a consent form is not
required. However, there must be a note on the face of the claim that states what medical
condition caused the sterility. Claims billed involving these situations will be denied for no
Sterilization Consent Form when an explanatory notation is not present on the face of
the claim.
The form must be legible in its entirety.
Transcervical Sterilizations
Procedure cCode 58579 is not covered for transcervical sterilization procedures. Procedure
cCode 58565 is to be used. The procedure must meet all sterilization requirements. PA is
required.
The Essure Kit is included in procedure code 58565 and should not be billed separately. The
invoice does not need to be attached to the claim.
If a beneficiary has had a transcervical hysteroscopy sterilization, a federal Sterilization
Consent Form is required. Additionally, three months must have passed before performing
code 58340. To indicate proof of sterilization, ICD-9 CM diagnosis code V25.2 must be
used. PA is not required.
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
BENEFITS & LIMITATIONS
8-38
APPENDIX I Updated 10/09
CODES
The Kansas Health Policy Authority (KHPA) requires KHPA Medical Plans hospital billers to submit
claims using the Health Care Financing Administration Common Procedure Code System (HCPCS).
HCPCS is a combination of codes which includes CPT® (Current Procedural Terminology) codes
created and controlled by the American Medical Association (AMA); Centers for Medicare &
Medicaid Services (CMS) codes created and controlled by CMS; and local codes created and
controlled by the regional CMS office. HCPCS codes consist of a five-digit base code with the
capability of being up to thirteen digits in length when modifiers are used. A modifier code is a
two-digit code that identifies a specific type of service, for example, anesthesia, or a variation of the
service identified by the base code. A chart has been developed to assist providers in understanding
how KHPA will handle specific modifiers. The Coding Modifiers chart is available on both the public
and secure portions of the website. It is under Reference Codes on the main provider page and
Pricing and Limitations on the secure portion. Information on the American Medical Association is
available at http://www.ama-assn.org. Certain services require a modifier code be given in addition to
the HCPCS base code. The modifier codes listed below are the only covered hospital modifier codes;
use of any other modifier codes may cause your claim to be denied.
*Note: Hospitals that bill the base code for radiology procedures will be reimbursed at
the TC rate.
Hospital billers should use CPT codes (refer to Section 1300) for outpatient services when available
or when specifically instructed to do so, otherwise the CMS or local codes printed in the following
pages should be used.
Not all codes are covered. Please use the following resources to determine coverage and pricing
information. For accuracy, use your provider type and specialty as well as the beneficiary ID number
or benefit plan.
• Information from the public website is available at:
https://www.kmap-state-ks.us/Provider/PRICING/RefCode.asp.
• Information from the secure website is available under Pricing and Limitations at:
https://www.kmap-state-ks.us/provider/security/logon.asp.
For further assistance, contact Customer Service at 1-800-933-6593. (Refer to Section 1000 of the
General Introduction Provider Manual.)
All claims must be coded with the appropriate codes. Claims which only describe the service and do
not provide the code will be denied. When a code is not available, the service is noncovered by
KHPA Medical Plans. Not otherwise classified (NOC) codes are noncovered. (Refer to Section 4200
of the General Special Requirements Provider Manual.)
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
APPENDIX I
AI-1
APPENDIX II Updated 10/09
Hospital Cost Report
To be eligible for payment from the KHPA Medical Plans, each hospital located in Kansas must
complete, sign and submit a copy of the cost report form (CMS 2552-96). An electronic copy of the
Electronic Cost Report (ECR) and Print Image (PI) files are required along with the signed
certification page. This must be done annually.
The cost report and its instructions can be obtained from Medicare.
Numerous private vendors offer services to assist in completing this cost report. KHPA has adopted
this cost report since it is already used by hospitals enrolled in the Medicare program. KHPA does
not require any Medicaid specific schedules to be completed, although they may be referred to in the
instructions. All general schedules of the report must be completed.
Submit the report to the following address:
Myers and Stauffer, LC.
Certified Public Accountants
4123 SW Gage Center Drive, Suite 200
Topeka, KS 66604-1833
For questions regarding the cost report, contact the above company at:
Telephone: 800-255-2309
785-228-6700
Fax: 800-228-6701
E-mail: [email protected]
KANSAS MEDICAL ASSISTANCE PROGRAM
HOSPITAL PROVIDER MANUAL
APPENDIX II
AII-1
DRG WEIGHTS AND RATES
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
Transfer
ALOS
DRG
001
002
003
004
005
006
007
008
009
010
011
012
013
020
021
022
023
024
025
026
027
028
029
030
031
032
033
034
035
036
037
038
039
040
041
042
052
053
Heart Transplant Or Implant Of Heart Assist System W MCC
Heart Transplant Or Implant Of Heart Assist System W/O MCC
ECMO Or Trach W MV 96+ Hrs Or PDX Exc Face, Mouth & Neck W Maj O.R.
Trach W MV 96+ Hrs Or PDX Exc Face, Mouth & Neck W/O Maj O.R.
Liver Transplant W MCC Or Intestinal Transplant
Liver Transplant W/O MCC
Lung Transplant
Simultaneous Pancreas/kidney Transplant
Bone Marrow Transplant
Pancreas Transplant
Tracheostomy For Face, Mouth & Neck Diagnoses W MCC
Tracheostomy For Face, Mouth & Neck Diagnoses W CC
Tracheostomy For Face, Mouth & Neck Diagnoses W/O CC/MCC
Intracranial Vascular Procedures W PDX Hemorrhage W MCC
Intracranial Vascular Procedures W PDX Hemorrhage W CC
Intracranial Vascular Procedures W PDX Hemorrhage W/O CC/MCC
Cranio W Major Dev Impl/Acute Complex CNS PDX W MCC Or Chemo Implan
Cranio W Major Dev Impl/Acute Complex CNS PDX W/O MCC
Craniotomy & Endovascular Intracranial Procedures W MCC
Craniotomy & Endovascular Intracranial Procedures W CC
Craniotomy & Endovascular Intracranial Procedures W/O CC/MCC
Spinal Procedures W MCC
Spinal Procedures W CC Or Spinal Neurostimulators
Spinal Procedures W/O CC/MCC
Ventricular Shunt Procedures W MCC
Ventricular Shunt Procedures W CC
Ventricular Shunt Procedures W/O CC/MCC
Carotid Artery Stent Procedure W MCC
Carotid Artery Stent Procedure W CC
Carotid Artery Stent Procedure W/O CC/MCC
Extracranial Procedures W MCC
Extracranial Procedures W CC
Extracranial Procedures W/O CC/MCC
Periph/Cranial Nerve & Other Nerv Syst Proc W MCC
Periph/Cranial Nerve & Other Nerv Syst Proc W CC Or Periph Neurostim
Periph/Cranial Nerve & Other Nerv Syst Proc W/O CC/MCC
Spinal Disorders & Injuries W CC/MCC
Spinal Disorders & Injuries W/O CC/MCC
20.5
14.2
39.7
22.0
16.2
8.4
13.1
7.9
22.8
8.9
11.7
8.8
6.0
16.1
18.4
9.6
8.8
7.1
11.0
6.8
3.7
12.0
5.8
3.0
8.2
3.6
2.3
4.9
2.2
1.3
5.5
2.6
1.3
9.5
4.4
2.9
4.6
2.8
1 of 20
DRG
Relative
Weight
27.7684
16.9659
25.7051
12.9309
21.5558
12.6758
19.9066
14.1481
12.4516
5.1997
5.3862
3.7763
2.5122
15.5019
8.0526
7.7971
6.9562
4.8036
7.3072
4.1467
2.5374
6.5226
3.7990
2.1581
5.3064
2.5306
1.8108
4.2273
2.5626
1.7481
3.7296
1.8376
1.1318
4.5783
2.2779
2.1277
1.8315
1.3221
DRG
Daily
Rate
5,852
5,161
2,804
2,547
5,774
6,525
6,593
7,782
2,364
2,529
1,998
1,858
1,804
4,176
1,897
3,516
3,438
2,945
2,870
2,636
2,945
2,359
2,816
3,135
2,791
3,010
3,423
3,773
5,020
5,959
2,930
3,083
3,828
2,084
2,257
3,176
1,716
2,044
Day
Outlier
Limit
76
40
148
65
56
24
30
14
57
22
59
19
18
42
27
21
29
24
39
24
9
44
29
10
40
19
13
19
11
5
23
11
5
34
14
6
17
9
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
584,066
297,069
466,420
143,820
489,762
229,785
385,601
209,810
345,181
107,437
214,141
92,473
71,052
344,326
50,835
144,959
165,981
115,663
68,024
41,117
20,326
191,678
127,005
68,049
199,698
81,893
57,262
110,096
75,114
37,363
116,762
52,014
9,000
133,145
21,724
17,364
78,449
35,423
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
054
055
056
057
058
059
060
061
062
063
064
065
066
067
068
069
070
071
072
073
074
075
076
077
078
079
080
081
082
083
084
085
086
087
088
089
090
091
092
Nervous System Neoplasms W MCC
Nervous System Neoplasms W/O MCC
Degenerative Nervous System Disorders W MCC
Degenerative Nervous System Disorders W/O MCC
Multiple Sclerosis & Cerebellar Ataxia W MCC
Multiple Sclerosis & Cerebellar Ataxia W CC
Multiple Sclerosis & Cerebellar Ataxia W/O CC/MCC
Acute Ischemic Stroke W Use Of Thrombolytic Agent W MCC
Acute Ischemic Stroke W Use Of Thrombolytic Agent W CC
Acute Ischemic Stroke W Use Of Thrombolytic Agent W/O CC/MCC
Intracranial Hemorrhage Or Cerebral Infarction W MCC
Intracranial Hemorrhage Or Cerebral Infarction W CC
Intracranial Hemorrhage Or Cerebral Infarction W/O CC/MCC
Nonspecific CVA & Precerebral Occlusion W/O Infarct W MCC
Nonspecific CVA & Precerebral Occlusion W/O Infarct W/O MCC
Transient Ischemia
Nonspecific Cerebrovascular Disorders W MCC
Nonspecific Cerebrovascular Disorders W CC
Nonspecific Cerebrovascular Disorders W/O CC/MCC
Cranial & Peripheral Nerve Disorders W MCC
Cranial & Peripheral Nerve Disorders W/O MCC
Viral Meningitis W CC/MCC
Viral Meningitis W/O CC/MCC
Hypertensive Encephalopathy W MCC
Hypertensive Encephalopathy W CC
Hypertensive Encephalopathy W/O CC/MCC
Nontraumatic Stupor & Coma W MCC
Nontraumatic Stupor & Coma W/O MCC
Traumatic Stupor & Coma, Coma >1 Hr W MCC
Traumatic Stupor & Coma, Coma >1 Hr W CC
Traumatic Stupor & Coma, Coma >1 Hr W/O CC/MCC
Traumatic Stupor & Coma, Coma <1 Hr W MCC
Traumatic Stupor & Coma, Coma <1 Hr W CC
Traumatic Stupor & Coma, Coma <1 Hr W/O CC/MCC
Concussion W MCC
Concussion W CC
Concussion W/O CC/MCC
Other Disorders Of Nervous System W MCC
Other Disorders Of Nervous System W CC
Transfer
ALOS
4.7
4.2
6.0
5.7
5.8
3.9
3.1
6.0
4.8
4.0
5.4
4.1
3.2
4.3
2.9
2.3
5.2
3.9
2.4
4.4
2.8
3.9
2.5
5.6
3.5
3.1
3.4
2.3
3.8
3.4
2.1
5.3
3.9
2.0
3.3
2.4
1.3
4.0
3.2
2 of 20
DRG
Relative
Weight
1.8484
1.5888
2.9161
1.6590
1.8867
1.0356
0.7785
3.6244
2.4888
2.0162
3.0543
1.8847
1.4407
1.6218
1.0130
0.9851
1.7290
1.0801
0.8266
1.4080
1.0987
1.2936
0.9233
2.4178
1.4319
0.9749
1.2923
0.5993
2.4920
1.5872
1.2155
2.6135
1.4920
0.8792
2.1409
1.1883
0.5616
1.6674
1.1901
DRG
Daily
Rate
1,702
1,638
2,104
1,267
1,408
1,147
1,101
2,602
2,226
2,177
2,439
1,985
1,967
1,633
1,528
1,887
1,445
1,211
1,510
1,385
1,675
1,429
1,592
1,872
1,761
1,344
1,660
1,118
2,877
2,033
2,554
2,139
1,652
1,913
2,775
2,180
1,899
1,787
1,590
Day
Outlier
Limit
21
14
20
25
16
11
8
18
11
9
23
14
19
13
8
5
18
11
7
15
9
13
6
18
11
7
16
8
16
11
7
21
13
6
11
8
3
16
12
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
73,951
16,723
58,989
22,870
43,165
35,290
22,783
94,219
52,769
38,879
37,759
22,170
21,705
38,028
31,701
9,173
57,365
31,762
24,533
50,992
12,851
43,809
9,185
81,357
38,090
25,199
39,956
15,618
72,700
40,191
33,877
94,383
41,411
24,695
66,594
36,151
5,262
70,378
32,818
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
093
094
095
096
097
098
099
100
101
102
103
113
114
115
116
117
121
122
123
124
125
129
130
131
132
133
134
135
136
137
138
139
146
147
148
149
150
151
152
Other Disorders Of Nervous System W/O CC/MCC
Bacterial & Tuberculous Infections Of Nervous System W MCC
Bacterial & Tuberculous Infections Of Nervous System W CC
Bacterial & Tuberculous Infections Of Nervous System W/O CC/MCC
Non-bacterial Infect Of Nervous Sys Exc Viral Meningitis W MCC
Non-bacterial Infect Of Nervous Sys Exc Viral Meningitis W CC
Non-bacterial Infect Of Nervous Sys Exc Viral Meningitis W/O CC/MCC
Seizures W MCC
Seizures W/O MCC
Headaches W MCC
Headaches W/O MCC
Orbital Procedures W CC/MCC
Orbital Procedures W/O CC/MCC
Extraocular Procedures Except Orbit
Intraocular Procedures W CC/MCC
Intraocular Procedures W/O CC/MCC
Acute Major Eye Infections W CC/MCC
Acute Major Eye Infections W/O CC/MCC
Neurological Eye Disorders
Other Disorders Of The Eye W MCC
Other Disorders Of The Eye W/O MCC
Major Head & Neck Procedures W CC/MCC Or Major Device
Major Head & Neck Procedures W/O CC/MCC
Cranial/facial Procedures W CC/MCC
Cranial/facial Procedures W/O CC/MCC
Other Ear, Nose, Mouth & Throat O.R. Procedures W CC/MCC
Other Ear, Nose, Mouth & Throat O.R. Procedures W/O CC/MCC
Sinus & Mastoid Procedures W CC/MCC
Sinus & Mastoid Procedures W/O CC/MCC
Mouth Procedures W CC/MCC
Mouth Procedures W/O CC/MCC
Salivary Gland Procedures
Ear, Nose, Mouth & Throat Malignancy W MCC
Ear, Nose, Mouth & Throat Malignancy W CC
Ear, Nose, Mouth & Throat Malignancy W/O CC/MCC
Dysequilibrium
Epistaxis W MCC
Epistaxis W/O MCC
Otitis Media & Uri W MCC
Transfer
ALOS
2.6
9.5
7.3
7.6
9.3
6.4
4.0
3.5
2.2
3.5
1.8
3.0
2.3
2.9
2.8
1.4
3.2
2.3
2.2
4.7
2.3
3.3
2.5
3.3
1.9
3.3
1.8
4.3
2.7
2.9
2.0
1.4
6.7
3.9
2.6
2.0
3.4
2.1
3.1
3 of 20
DRG
Relative
Weight
0.7928
3.7797
2.7192
2.9173
3.2667
2.3808
1.3015
1.5887
0.8024
1.1876
0.7334
2.0119
1.6149
1.4384
1.6678
0.8871
0.7886
0.4807
0.7896
1.5008
0.6890
2.6785
1.5841
2.5856
1.0296
1.9728
0.9043
2.2525
1.4347
1.1551
0.7146
0.9647
2.5895
1.0215
0.7842
0.6188
0.9966
0.5424
0.9845
DRG
Daily
Rate
1,310
1,728
1,610
1,671
1,526
1,618
1,412
1,976
1,593
1,490
1,725
2,865
3,040
2,185
2,606
2,845
1,070
889
1,575
1,379
1,314
3,557
2,743
3,392
2,358
2,588
2,199
2,268
2,300
1,701
1,524
2,920
1,673
1,128
1,316
1,353
1,288
1,129
1,366
Day
Outlier
Limit
10
32
21
12
26
26
11
11
7
13
8
11
8
9
14
5
10
6
5
14
9
11
7
14
7
18
6
13
8
12
6
4
18
14
9
6
13
6
14
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
12,788
96,636
81,982
17,411
106,191
85,108
38,705
18,204
9,367
43,941
9,064
55,928
44,788
34,821
55,605
23,547
24,719
13,521
19,109
35,827
23,533
75,285
37,337
78,957
8,149
87,137
27,004
50,262
32,087
48,377
16,559
23,599
56,800
29,562
22,613
15,749
37,280
17,903
74,280
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
153
154
155
156
157
158
159
163
164
165
166
167
168
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
Otitis Media & Uri W/O MCC
Nasal Trauma & Deformity W MCC
Nasal Trauma & Deformity W CC
Nasal Trauma & Deformity W/O CC/MCC
Dental & Oral Diseases W MCC
Dental & Oral Diseases W CC
Dental & Oral Diseases W/O CC/MCC
Major Chest Procedures W MCC
Major Chest Procedures W CC
Major Chest Procedures W/O CC/MCC
Other Resp System O.R. Procedures W MCC
Other Resp System O.R. Procedures W CC
Other Resp System O.R. Procedures W/O CC/MCC
Pulmonary Embolism W MCC
Pulmonary Embolism W/O MCC
Respiratory Infections & Inflammations W MCC
Respiratory Infections & Inflammations W CC
Respiratory Infections & Inflammations W/O CC/MCC
Respiratory Neoplasms W MCC
Respiratory Neoplasms W CC
Respiratory Neoplasms W/O CC/MCC
Major Chest Trauma W MCC
Major Chest Trauma W CC
Major Chest Trauma W/O CC/MCC
Pleural Effusion W MCC
Pleural Effusion W CC
Pleural Effusion W/O CC/MCC
Pulmonary Edema & Respiratory Failure
Chronic Obstructive Pulmonary Disease W MCC
Chronic Obstructive Pulmonary Disease W CC
Chronic Obstructive Pulmonary Disease W/O CC/MCC
Simple Pneumonia & Pleurisy W MCC
Simple Pneumonia & Pleurisy W CC
Simple Pneumonia & Pleurisy W/O CC/MCC
Interstitial Lung Disease W MCC
Interstitial Lung Disease W CC
Interstitial Lung Disease W/O CC/MCC
Pneumothorax W MCC
Pneumothorax W CC
Transfer
ALOS
2.0
6.5
3.2
2.0
4.3
3.0
1.6
9.6
5.8
3.5
9.1
5.5
3.6
6.3
4.6
7.8
5.9
4.9
7.0
5.0
2.8
5.6
3.2
2.4
5.2
4.0
2.9
4.0
4.2
3.4
2.9
4.0
3.1
2.4
5.0
4.4
3.0
5.8
4.2
4 of 20
DRG
Relative
Weight
0.6224
2.2793
0.8932
0.6080
1.7520
0.8691
0.5738
5.8103
3.5661
2.2105
3.6934
2.7850
1.3162
2.4534
1.9539
3.1838
2.0190
1.5965
2.9888
2.1262
0.7204
1.7161
1.0155
0.8253
1.5589
1.1693
0.8186
1.8221
1.7006
1.3036
1.0898
1.7268
1.0937
0.8044
1.4354
1.2181
0.7900
1.9449
1.5931
DRG
Daily
Rate
1,340
1,523
1,224
1,303
1,764
1,271
1,582
2,617
2,666
2,758
1,767
2,176
1,601
1,697
1,839
1,758
1,489
1,422
1,843
1,826
1,110
1,322
1,387
1,501
1,293
1,281
1,214
1,972
1,757
1,685
1,605
1,883
1,518
1,439
1,243
1,188
1,144
1,452
1,654
Day
Outlier
Limit
5
14
11
7
15
10
4
32
12
8
28
17
10
13
11
25
16
15
20
19
9
18
9
6
18
13
8
13
12
10
7
13
9
6
15
15
8
19
11
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
6,966
16,671
29,112
20,537
69,070
27,891
5,094
63,921
30,076
17,684
122,217
27,392
34,323
19,455
19,121
38,909
21,214
17,114
29,754
23,027
21,881
50,584
28,098
20,321
45,606
34,955
20,259
23,004
20,140
14,581
10,625
22,689
12,676
8,934
43,163
35,705
21,721
56,994
14,873
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
201
202
203
204
205
206
207
208
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
Pneumothorax W/O CC/MCC
Bronchitis & Asthma W CC/MCC
Bronchitis & Asthma W/O CC/MCC
Respiratory Signs & Symptoms
Other Respiratory System Diagnoses W MCC
Other Respiratory System Diagnoses W/O MCC
Respiratory System Diagnosis W Ventilator Support 96+ Hours
Respiratory System Diagnosis W Ventilator Support <96 Hours
Other Heart Assist System Implant
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W MCC
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W CC
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W/O CC/MCC
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W MCC
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W CC
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W/O CC/MCC
Cardiac Defib Implant W Cardiac Cath W AMI/HF/Shock W MCC
Cardiac Defib Implant W Cardiac Cath W AMI/HF/Shock W/O MCC
Cardiac Defib Implant W Cardiac Cath W/O AMI/HF/Shock W MCC
Cardiac Defib Implant W Cardiac Cath W/O AMI/HF/Shock W/O MCC
Cardiac Defibrillator Implant W/O Cardiac Cath W MCC
Cardiac Defibrillator Implant W/O Cardiac Cath W/O MCC
Other Cardiothoracic Procedures W MCC
Other Cardiothoracic Procedures W CC
Other Cardiothoracic Procedures W/O CC/MCC
Coronary Bypass W PTCA W MCC
Coronary Bypass W PTCA W/O MCC
Coronary Bypass W Cardiac Cath W MCC
Coronary Bypass W Cardiac Cath W/O MCC
Coronary Bypass W/O Cardiac Cath W MCC
Coronary Bypass W/O Cardiac Cath W/O MCC
Major Cardiovasc Procedures W MCC Or Thoracic Aortic Anuerysm Repair
Major Cardiovasc Procedures W/O MCC
Amputation For Circ Sys Disorders Exc Upper Limb & Toe W MCC
Amputation For Circ Sys Disorders Exc Upper Limb & Toe W CC
Amputation For Circ Sys Disorders Exc Upper Limb & Toe W/O CC/MCC
Permanent Cardiac Pacemaker Implant W MCC
Permanent Cardiac Pacemaker Implant W CC
Permanent Cardiac Pacemaker Implant W/O CC/MCC
AICD Generator Procedures
Transfer
ALOS
3.7
2.8
2.1
1.9
3.8
2.4
15.4
5.2
7.0
13.9
10.0
7.1
12.0
6.9
5.5
10.5
5.1
8.1
5.3
6.2
1.9
9.4
6.9
5.0
9.5
8.1
10.8
8.0
8.6
5.9
8.0
4.7
13.3
8.6
5.9
6.5
3.8
2.5
1.8
5 of 20
DRG
Relative
Weight
1.1128
0.9928
0.7168
0.8253
1.4423
0.9638
7.2933
2.9815
15.6049
10.4879
7.5216
5.8771
11.2621
6.4089
5.2342
9.9694
6.8549
9.2964
4.8990
7.3765
4.7067
8.4690
5.6145
4.5885
8.2741
6.7118
7.2571
5.6823
5.5302
5.0101
6.5766
3.8041
4.8294
2.6940
1.7849
3.7698
2.7230
2.3487
4.1010
DRG
Daily
Rate
1,320
1,524
1,478
1,851
1,643
1,760
2,057
2,487
9,651
3,276
3,259
3,604
4,049
4,009
4,158
4,122
5,785
4,968
3,979
5,150
10,503
3,917
3,512
3,949
3,782
3,609
2,906
3,079
2,777
3,670
3,568
3,526
1,571
1,350
1,301
2,518
3,143
4,116
10,087
Day
Outlier
Limit
6
8
6
6
13
7
50
21
18
34
22
13
31
20
11
28
15
27
15
26
7
36
20
13
22
15
41
12
16
11
36
14
39
25
15
19
12
5
8
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
8,272
11,054
7,834
9,258
51,096
10,282
76,090
35,435
309,294
239,784
159,036
105,684
82,797
52,496
99,755
225,418
138,078
210,311
34,741
169,496
46,069
252,239
146,987
103,789
184,664
131,613
73,892
41,703
41,744
37,578
206,298
50,751
140,199
75,601
57,325
92,661
65,141
18,294
103,082
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
Perc Cardiovasc Proc W Drug-Eluting Stent W MCC Or 4+ Vessels/Stents
Perc Cardiovasc Proc W Drug-Eluting Stent W/O MCC
Perc Cardiovasc Proc W Non-Drug-Eluting Stent W MCC Or 4+ Ves/Stents
Perc Cardiovasc Proc W Non-Drug-Eluting Stent W/O MCC
Perc Cardiovasc Proc W/O Coronary Artery Stent Or AMI W MCC
Perc Cardiovasc Proc W/O Coronary Artery Stent Or AMI W/O MCC
Other Vascular Procedures W MCC
Other Vascular Procedures W CC
Other Vascular Procedures W/O CC/MCC
Upper Limb & Toe Amputation For Circ System Disorders W MCC
Upper Limb & Toe Amputation For Circ System Disorders W CC
Upper Limb & Toe Amputation For Circ System Disorders W/O CC/MCC
Cardiac Pacemaker Device Replacement W MCC
Cardiac Pacemaker Device Replacement W/O MCC
Cardiac Pacemaker Revision Except Device Replacement W MCC
Cardiac Pacemaker Revision Except Device Replacement W CC
Cardiac Pacemaker Revision Except Device Replacement W/O CC/MCC
Vein Ligation & Stripping
Other Circulatory System O.R. Procedures
AICD Lead Procedures
Acute Myocardial Infarction, Discharged Alive W MCC
Acute Myocardial Infarction, Discharged Alive W CC
Acute Myocardia Infarction, Discharged Alive W/O CC/MCC
Acute Myocardial Infarction, Expired W MCC
Acute Myocardial Infarction, Expired W CC
Acute Myocardial Infarction, Expired W/O CC/MCC
Circulatory Disorders Except AMI, W Card Cath W MCC
Circulatory Disorders Except AMI, W Card Cath W/O MCC
Acute & Subacute Endocarditis W MCC
Acute & Subacute Endocarditis W CC
Acute & Subacute Endocarditis W/O CC/MCC
Heart Failure & Shock W MCC
Heart Failure & Shock W CC
Heart Failure & Shock W/O CC/MCC
Deep Vein Thrombophlebitis W CC/MCC
Deep Vein Thrombophlebitis W/O CC/MCC
Cardiac Arrest, Unexplained W MCC
Cardiac Arrest, Unexplained W CC
Cardiac Arrest, Unexplained W/O CC/MCC
Transfer
ALOS
4.1
1.9
3.8
2.5
4.8
2.5
5.6
3.6
2.4
7.5
5.5
3.0
5.0
2.4
7.4
2.8
1.9
3.3
7.3
1.9
5.1
3.4
2.9
3.1
2.2
1.7
5.1
2.4
9.3
6.5
4.4
4.8
3.6
2.8
4.2
3.4
2.1
1.4
1.1
6 of 20
DRG
Relative
Weight
4.5847
2.4913
3.2606
2.6206
3.5167
2.1766
3.2217
2.6690
2.1119
2.4417
1.5075
0.9149
3.4062
1.8413
4.0083
1.4625
0.9995
1.9659
2.9934
1.9556
2.5732
1.9488
1.5548
1.8200
0.9512
0.6734
2.8708
1.4561
3.0533
1.7739
0.9695
2.1178
1.4702
1.0729
0.8562
0.4231
1.7749
0.8154
0.5436
DRG
Daily
Rate
4,829
5,767
3,764
4,556
3,198
3,739
2,495
3,209
3,794
1,415
1,189
1,303
2,949
3,321
2,345
2,302
2,277
2,579
1,768
4,576
2,197
2,452
2,337
2,533
1,863
1,735
2,427
2,583
1,429
1,189
945
1,894
1,773
1,677
880
540
3,676
2,521
2,139
Day
Outlier
Limit
20
5
13
6
20
6
16
13
8
23
16
11
14
8
19
9
6
11
20
8
17
8
6
15
10
6
14
7
35
25
12
17
11
7
10
8
11
8
7
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
48,051
19,891
30,137
21,529
100,261
18,613
30,634
26,407
20,783
71,910
44,590
20,962
72,644
38,936
84,323
36,301
27,756
44,701
28,836
56,959
31,920
17,266
12,531
74,043
29,384
21,860
34,613
15,538
88,543
42,793
23,109
26,917
15,503
10,271
28,964
13,405
59,562
22,382
17,109
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
Peripheral Vascular Disorders W MCC
Peripheral Vascular Disorders W CC
Peripheral Vascular Disorders W/O CC/MCC
Atherosclerosis W MCC
Atherosclerosis W/O MCC
Hypertension W MCC
Hypertension W/O MCC
Cardiac Congenital & Valvular Disorders W MCC
Cardiac Congenital & Valvular Disorders W/O MCC
Cardiac Arrhythmia & Conduction Disorders W MCC
Cardiac Arrhythmia & Conduction Disorders W CC
Cardiac Arrhythmia & Conduction Disorders W/O CC/MCC
Angina Pectoris
Syncope & Collapse
Chest Pain
Other Circulatory System Diagnoses W MCC
Other Circulatory System Diagnoses W CC
Other Circulatory System Diagnoses W/O CC/MCC
Stomach, Esophageal & Duodenal Proc W MCC
Stomach, Esophageal & Duodenal Proc W CC
Stomach, Esophageal & Duodenal Proc W/O CC/MCC
Major Small & Large Bowel Procedures W MCC
Major Small & Large Bowel Procedures W CC
Major Small & Large Bowel Procedures W/O CC/MCC
Rectal Resection W MCC
Rectal Resection W CC
Rectal Resection W/O CC/MCC
Peritoneal Adhesiolysis W MCC
Peritoneal Adhesiolysis W CC
Peritoneal Adhesiolysis W/O CC/MCC
Appendectomy W Complicated Principal Diag W MCC
Appendectomy W Complicated Principal Diag W CC
Appendectomy W Complicated Principal Diag W/O CC/MCC
Appendectomy W/O Complicated Principal Diag W MCC
Appendectomy W/O Complicated Principal Diag W CC
Appendectomy W/O Complicated Principal Diag W/O CC/MCC
Minor Small & Large Bowel Procedures W MCC
Minor Small & Large Bowel Procedures W CC
Minor Small & Large Bowel Procedures W/O CC/MCC
Transfer
ALOS
4.7
4.3
2.9
2.8
1.9
3.1
2.3
4.1
2.7
3.9
2.2
1.9
1.6
2.2
1.7
5.0
3.3
2.2
10.5
5.5
3.1
13.8
8.4
4.8
11.4
7.0
5.0
14.8
6.8
3.7
7.4
6.2
4.2
3.7
2.2
1.7
8.2
6.0
4.9
7 of 20
DRG
Relative
Weight
2.3172
1.3287
1.0063
0.9367
0.8596
1.0762
1.0116
1.5904
0.8250
1.3485
0.9871
0.8011
0.7961
0.9140
0.8365
2.5882
1.2209
0.6752
6.0020
2.5099
1.3860
7.2053
3.7700
1.6742
4.5088
2.3539
1.8838
5.9082
3.0799
1.8696
3.2851
2.3455
1.8318
1.8524
1.3975
1.1181
3.0090
2.2113
1.4734
DRG
Daily
Rate
2,148
1,328
1,513
1,443
2,001
1,523
1,888
1,679
1,323
1,485
1,960
1,845
2,127
1,807
2,168
2,227
1,587
1,341
2,465
1,986
1,942
2,259
1,936
1,523
1,708
1,460
1,621
1,729
1,949
2,193
1,917
1,638
1,902
2,191
2,788
2,916
1,587
1,601
1,304
Day
Outlier
Limit
14
19
7
9
5
13
6
13
10
14
7
6
4
7
5
17
9
7
37
16
11
64
32
12
30
15
11
32
20
10
23
12
8
13
7
4
30
16
8
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
48,951
21,545
9,569
23,880
9,599
48,581
11,634
37,417
30,083
55,474
9,908
8,758
7,212
9,531
8,975
33,841
14,668
19,658
79,444
28,497
21,795
98,672
55,364
42,061
119,849
56,449
41,384
47,994
29,172
18,151
108,575
17,322
16,359
54,551
12,451
9,059
126,390
39,206
16,210
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
347
348
349
350
351
352
353
354
355
356
357
358
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
Anal & Stomal Procedures W MCC
Anal & Stomal Procedures W CC
Anal & Stomal Procedures W/O CC/MCC
Inguinal & Femoral Hernia Procedures W MCC
Inguinal & Femoral Hernia Procedures W CC
Inguinal & Femoral Hernia Procedures W/O CC/MCC
Hernia Procedures Except Inguinal & Femoral W MCC
Hernia Procedures Except Inguinal & Femoral W CC
Hernia Procedures Except Inguinal & Femoral W/O CC/MCC
Other Digestive System O.R. Procedures W MCC
Other Digestive System O.R. Procedures W CC
Other Digestive System O.R. Procedures W/O CC/MCC
Major Esophageal Disorders W MCC
Major Esophageal Disorders W CC
Major Esophageal Disorders W/O CC/MCC
Major Gastrointestinal Disorders & Peritoneal Infections W MCC
Major Gastrointestinal Disorders & Peritoneal Infections W CC
Major Gastrointestinal Disorders & Peritoneal Infections W/O CC/MCC
Digestive Malignancy W MCC
Digestive Malignancy W CC
Digestive Malignancy W/O CC/MCC
G.I. Hemorrhage W MCC
G.I. Hemorrhage W CC
G.I. Hemorrhage W/O CC/MCC
Complicated Peptic Ulcer W MCC
Complicated Peptic Ulcer W CC
Complicated Peptic Ulcer W/O CC/MCC
Uncomplicated Peptic Ulcer W MCC
Uncomplicated Peptic Ulcer W/O MCC
Inflammatory Bowel Disease W MCC
Inflammatory Bowel Disease W CC
Inflammatory Bowel Disease W/O CC/MCC
G.I. Obstruction W MCC
G.I. Obstruction W CC
G.I. Obstruction W/O CC/MCC
Esophagitis, Gastroent & Misc Digest Disorders W MCC
Esophagitis, Gastroent & Misc Digest Disorders W/O MCC
Other Digestive System Diagnoses W MCC
Other Digestive System Diagnoses W CC
Transfer
ALOS
6.3
3.5
2.3
5.4
3.2
1.7
6.3
5.5
2.3
8.8
5.6
3.2
5.5
4.5
2.2
6.9
4.7
3.4
5.7
4.5
3.0
3.8
3.2
2.3
5.4
4.0
2.5
4.5
2.5
5.1
3.7
3.4
5.0
3.7
2.1
3.3
2.4
4.4
3.5
8 of 20
DRG
Relative
Weight
2.4170
1.2361
0.7845
2.5170
1.2152
0.8129
3.3045
2.3904
1.0389
4.0360
2.1995
1.4076
2.0969
1.5924
0.7505
2.6283
1.6765
0.9389
1.9897
1.6683
0.8252
1.9870
1.4289
1.0127
1.7158
1.1583
0.7805
1.5346
1.0556
1.7744
1.2807
0.8533
1.7087
1.1142
0.6959
1.3774
0.9027
1.5372
1.3751
DRG
Daily
Rate
1,666
1,516
1,509
2,014
1,629
2,034
2,271
1,892
1,990
1,983
1,697
1,892
1,647
1,549
1,497
1,649
1,541
1,206
1,508
1,594
1,211
2,252
1,939
1,873
1,378
1,269
1,335
1,476
1,828
1,506
1,490
1,099
1,482
1,311
1,462
1,801
1,608
1,516
1,720
Day
Outlier
Limit
25
11
7
35
10
6
32
34
8
33
19
10
17
9
6
23
19
10
25
14
10
14
9
5
16
11
6
17
7
18
12
10
12
10
6
12
9
17
12
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
88,347
35,250
21,164
110,805
28,430
19,310
161,417
26,489
31,584
127,941
67,635
35,576
65,977
11,055
17,853
27,541
20,532
9,811
69,492
18,424
24,791
22,708
15,950
9,740
51,883
32,481
17,814
52,274
9,720
97,701
28,174
11,106
16,429
11,540
7,487
20,179
11,046
61,848
17,520
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
395
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
453
454
Other Digestive System Diagnoses W/O CC/MCC
Pancreas, Liver & Shunt Procedures W MCC
Pancreas, Liver & Shunt Procedures W CC
Pancreas, Liver & Shunt Procedures W/O CC/MCC
Biliary Tract Proc Except Only Cholecyst W/OR W/O C.D.E. W MCC
Biliary Tract Proc Except Only Cholecyst W/OR W/O C.D.E. W CC
Biliary Tract Proc Except Only Cholecyst W/OR W/O C.D.E. W/O CC/MCC
Cholecystectomy W C.D.E. W MCC
Cholecystectomy W C.D.E. W CC
Cholecystectomy W C.D.E. W/O CC/MCC
Cholecystectomy Except By Laparoscope W/O C.D.E. W MCC
Cholecystectomy Except By Laparoscope W/O C.D.E. W CC
Cholecystectomy Except By Laparoscope W/O C.D.E. W/O CC/MCC
Laparoscopic Cholecystectomy W/O C.D.E. W MCC
Laparoscopic Cholecystectomy W/O C.D.E. W CC
Laparoscopic Cholecystectomy W/O C.D.E. W/O CC/MCC
Hepatobiliary Diagnostic Procedures W MCC
Hepatobiliary Diagnostic Procedures W CC
Hepatobiliary Diagnostic Procedures W/O CC/MCC
Other Hepatobiliary Or Pancreas O.R. Procedures W MCC
Other Hepatobiliary Or Pancreas O.R. Procedures W CC
Other Hepatobiliary Or Pancreas O.R. Procedures W/O CC/MCC
Cirrhosis & Alcoholic Hepatitis W MCC
Cirrhosis & Alcoholic Hepatitis W CC
Cirrhosis & Alcoholic Hepatitis W/O CC/MCC
Malignancy Of Hepatobiliary System Or Pancreas W MCC
Malignancy Of Hepatobiliary System Or Pancreas W CC
Malignancy Of Hepatobiliary System Or Pancreas W/O CC/MCC
Disorders Of Pancreas Except Malignancy W MCC
Disorders Of Pancreas Except Malignancy W CC
Disorders Of Pancreas Except Malignancy W/O CC/MCC
Disorders Of Liver Except Malig, Cirr, Alc Hepa W MCC
Disorders Of Liver Except Malig, Cirr, Alc Hepa W CC
Disorders Of Liver Except Malig, Cirr, Alc Hepa W/O CC/MCC
Disorders Of The Biliary Tract W MCC
Disorders Of The Biliary Tract W CC
Disorders Of The Biliary Tract W/O CC/MCC
Combined Anterior/Posterior Spinal Fusion W MCC
Combined Anterior/Posterior Spinal Fusion W CC
Transfer
ALOS
2.2
12.4
6.2
4.0
11.5
6.9
5.7
9.0
5.0
3.6
9.1
5.5
3.7
4.9
3.2
2.3
10.9
5.7
3.5
10.7
7.7
3.9
5.6
3.4
2.6
5.1
3.0
2.8
5.5
3.7
2.9
4.9
3.3
2.4
4.4
3.8
2.3
14.1
4.6
9 of 20
DRG
Relative
Weight
0.8243
7.6006
3.3021
2.3889
4.9380
2.5828
2.2642
4.2417
2.1522
1.6965
3.8089
2.1035
1.4361
2.4238
1.7496
1.4719
5.6047
2.2532
1.5381
5.3825
3.1199
1.7608
2.4755
1.1514
0.6820
1.8279
1.1676
0.9312
2.7147
1.2671
1.0450
2.3638
1.3194
0.8574
1.5295
1.4017
0.7194
14.1304
4.6936
DRG
Daily
Rate
1,660
2,653
2,302
2,579
1,865
1,628
1,714
2,049
1,849
2,029
1,812
1,659
1,699
2,137
2,382
2,770
2,220
1,717
1,892
2,170
1,747
1,954
1,924
1,449
1,149
1,552
1,663
1,450
2,133
1,503
1,571
2,084
1,741
1,553
1,505
1,610
1,378
4,329
4,436
Day
Outlier
Limit
6
43
22
11
33
20
14
26
13
10
25
15
9
14
7
8
30
21
11
42
31
12
21
10
8
17
10
9
22
11
8
25
12
5
15
9
6
54
11
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
9,419
253,942
86,176
57,516
139,031
64,534
52,250
136,392
45,868
37,465
120,591
53,573
34,213
23,388
14,851
14,652
178,405
82,256
37,261
215,088
96,859
40,723
32,013
12,852
19,775
56,536
11,854
25,392
38,069
13,874
11,599
37,331
17,261
9,093
52,235
13,794
18,519
376,249
28,760
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
Combined Anterior/Posterior Spinal Fusion W/O CC/MCC
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec Or 9+ Fus W MCC
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec Or 9+ Fus W CC
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec Or 9+ Fus W/O CC/MCC
Spinal Fusion Except Cervical W MCC
Spinal Fusion Except Cervical W/O MCC
Bilateral Or Multiple Major Joint Procs Of Lower Extremity W MCC
Bilateral Or Multiple Major Joint Procs Of Lower Extremity W/O MCC
Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W MCC
Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W CC
Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W/O CC/MCC
Revision Of Hip Or Knee Replacement W MCC
Revision Of Hip Or Knee Replacement W CC
Revision Of Hip Or Knee Replacement W/O CC/MCC
Major Joint Replacement Or Reattachment Of Lower Extremity W MCC
Major Joint Replacement Or Reattachment Of Lower Extremity W/O MCC
Cervical Spinal Fusion W MCC
Cervical Spinal Fusion W CC
Cervical Spinal Fusion W/O CC/MCC
Amputation For Musculoskeletal Sys & Conn Tissue Dis W MCC
Amputation For Musculoskeletal Sys & Conn Tissue Dis W CC
Amputation For Musculoskeletal Sys & Conn Tissue Dis W/O CC/MCC
Biopsies Of Musculoskeletal System & Connective Tissue W MCC
Biopsies Of Musculoskeletal System & Connective Tissue W CC
Biopsies Of Musculoskeletal System & Connective Tissue W/O CC/MCC
Hip & Femur Procedures Except Major Joint W MCC
Hip & Femur Procedures Except Major Joint W CC
Hip & Femur Procedures Except Major Joint W/O CC/MCC
Major Joint & Limb Reattachment Proc Of Upper Extremity W CC/MCC
Major Joint & Limb Reattachment Proc Of Upper Extremity W/O CC/MCC
Knee Procedures W PDX Of Infection W MCC
Knee Procedures W PDX Of Infection W CC
Knee Procedures W PDX Of Infection W/O CC/MCC
Knee Procedures W/O PDX Of Infection W CC/MCC
Knee Procedures W/O PDX Of Infection W/O CC/MCC
Back & Neck Proc Exc Spinal Fusion W CC/MCC Or Disc Device/Neurostim
Back & Neck Proc Exc Spinal Fusion W/O CC/MCC
Lower Extrem & Humer Proc Except Hip, Foot, Femur W MCC
Lower Extrem & Humer Proc Except Hip, Foot, Femur W CC
Transfer
ALOS
4.8
16.0
10.0
4.8
7.8
3.6
7.3
3.5
12.1
6.9
4.3
7.6
5.5
3.5
7.2
3.4
7.2
2.3
1.8
9.5
6.6
4.0
10.4
5.4
2.4
7.5
6.0
3.7
3.4
2.0
9.9
6.3
4.2
3.4
2.2
3.0
2.0
6.8
3.8
10 of 20
DRG
Relative
Weight
3.1271
8.8801
7.5908
5.8891
5.3060
3.8848
4.9536
4.5936
4.9562
2.7414
2.2367
7.6171
4.3676
3.5932
3.4332
2.8295
5.2291
2.2542
1.8384
3.5963
2.5497
1.5038
3.9172
2.1526
1.5716
3.0527
2.9364
1.8000
2.3638
1.7187
3.2188
1.9959
1.3475
1.6470
1.3034
2.0234
1.2237
3.2502
2.1098
DRG
Daily
Rate
2,838
2,403
3,299
5,345
2,945
4,646
2,958
5,698
1,778
1,717
2,236
4,333
3,463
4,509
2,076
3,613
3,140
4,224
4,373
1,646
1,680
1,619
1,631
1,742
2,871
1,757
2,122
2,100
3,019
3,702
1,406
1,378
1,392
2,103
2,576
2,920
2,662
2,066
2,378
Day
Outlier
Limit
15
41
20
9
14
8
17
6
42
30
16
25
16
6
20
6
23
11
5
30
20
9
38
15
9
20
12
9
11
5
29
15
9
10
6
9
6
20
9
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
32,681
66,656
52,676
128,732
35,822
36,093
131,001
32,818
148,684
96,601
72,039
113,847
45,150
31,229
96,226
22,409
129,328
21,719
17,787
115,478
21,919
10,531
145,123
51,484
34,089
86,728
28,252
16,690
56,405
34,903
86,530
49,165
33,034
39,746
33,683
18,885
9,609
103,340
17,373
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
Lower Extrem & Humer Proc Except Hip, Foot, Femur W/O CC/MCC
Local Excision & Removal Int Fix Devices Exc Hip & Femur W MCC
Local Excision & Removal Int Fix Devices Exc Hip & Femur W CC
Local Excision & Removal Int Fix Devices Exc Hip & Femur W/O CC/MCC
Local Excision & Removal Int Fix Devices Of Hip & Femur W CC/MCC
Local Excision & Removal Int Fix Devices Of Hip & Femur W/O CC/MCC
Soft Tissue Procedures W MCC
Soft Tissue Procedures W CC
Soft Tissue Procedures W/O CC/MCC
Foot Procedures W MCC
Foot Procedures W CC
Foot Procedures W/O CC/MCC
Major Thumb Or Joint Procedures
Major Shoulder Or Elbow Joint Procedures W CC/MCC
Major Shoulder Or Elbow Joint Procedures W/O CC/MCC
Arthroscopy
Shoulder, Elbow Or Forearm Proc, Exc Major Joint Proc W MCC
Shoulder, Elbow Or Forearm Proc, Exc Major Joint Proc W CC
Shoulder, Elbow Or Forearm Proc, Exc Major Joint Proc W/O CC/MCC
Hand Or Wrist Proc, Except Major Thumb Or Joint Proc W CC/MCC
Hand Or Wrist Proc, Except Major Thumb Or Joint Proc W/O CC/MCC
Other Musculoskelet Sys & Conn Tiss O.R. Proc W MCC
Other Musculoskelet Sys & Conn Tiss O.R. Proc W CC
Other Musculoskelet Sys & Conn Tiss O.R. Proc W/O CC/MCC
Fractures Of Femur W MCC
Fractures Of Femur W/O MCC
Fractures Of Hip & Pelvis W MCC
Fractures Of Hip & Pelvis W/O MCC
Sprains, Strains, & Dislocations Of Hip, Pelvis & Thigh W CC/MCC
Sprains, Strains, & Dislocations Of Hip, Pelvis & Thigh W/O CC/MCC
Osteomyelitis W MCC
Osteomyelitis W CC
Osteomyelitis W/O CC/MCC
Pathological Fractures & Musculoskelet & Conn Tiss Malig W MCC
Pathological Fractures & Musculoskelet & Conn Tiss Malig W CC
Pathological Fractures & Musculoskelet & Conn Tiss Malig W/O CC/MCC
Connective Tissue Disorders W MCC
Connective Tissue Disorders W CC
Connective Tissue Disorders W/O CC/MCC
Transfer
ALOS
2.4
7.7
4.2
2.7
5.4
2.2
6.4
5.0
2.5
7.4
4.6
3.2
2.1
3.1
1.9
1.7
5.0
2.8
1.8
2.8
2.0
8.0
4.7
2.2
5.1
2.5
4.9
3.4
3.2
2.2
7.0
6.1
4.1
6.4
4.6
3.6
6.2
4.0
2.8
11 of 20
DRG
Relative
Weight
1.4215
4.3401
1.7362
1.5807
1.9499
1.0262
3.5566
2.1206
1.4192
2.3971
1.6737
1.1597
1.1186
1.6677
1.4706
1.1597
2.4853
1.4721
1.1214
1.4331
0.9664
2.6644
2.2531
1.6303
1.1206
0.6120
1.4296
0.6009
0.7966
0.5270
1.9909
1.8000
0.8250
1.9986
1.1304
0.6944
2.9519
1.1358
0.8397
DRG
Daily
Rate
2,619
2,440
1,777
2,507
1,578
2,066
2,409
1,829
2,448
1,395
1,579
1,569
2,263
2,344
3,368
2,885
2,174
2,268
2,682
2,184
2,145
1,451
2,071
3,151
949
1,068
1,253
763
1,081
1,028
1,235
1,271
878
1,350
1,066
837
2,054
1,235
1,317
Day
Outlier
Limit
6
42
15
8
35
8
24
11
7
21
14
7
6
10
3
6
12
8
5
12
7
14
15
6
15
13
14
9
8
7
22
12
20
21
15
9
28
9
8
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
12,859
200,568
49,005
11,085
59,781
33,276
96,777
17,720
10,626
65,398
52,264
8,983
36,712
39,936
10,527
24,302
69,928
36,347
27,448
38,097
29,644
17,417
65,538
11,535
30,607
15,244
53,930
16,513
20,728
13,610
61,098
14,600
27,060
74,966
35,300
21,753
143,906
11,704
35,380
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
573
574
575
576
577
578
579
580
581
582
583
584
585
592
593
594
595
596
597
598
Septic Arthritis W MCC
Septic Arthritis W CC
Septic Arthritis W/O CC/MCC
Medical Back Problems W MCC
Medical Back Problems W/O MCC
Bone Diseases & Arthropathies W MCC
Bone Diseases & Arthropathies W/O MCC
Signs & Symptoms Of Musculoskeletal System & Conn Tissue W MCC
Signs & Symptoms Of Musculoskeletal System & Conn Tissue W/O MCC
Tendonitis, Myositis & Bursitis W MCC
Tendonitis, Myositis & Bursitis W/O MCC
Aftercare, Musculoskeletal System & Connective Tissue W MCC
Aftercare, Musculoskeletal System & Connective Tissue W CC
Aftercare, Musculoskeletal System & Connective Tissue W/O CC/MCC
Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh W MCC
Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh W/O MCC
Other Musculoskeletal Sys & Connective Tissue Diagnoses W MCC
Other Musculoskeletal Sys & Connective Tissue Diagnoses W CC
Other Musculoskeletal Sys & Connective Tissue Diagnoses W/O CC/MCC
Skin Graft &/or Debrid For Skn Ulcer Or Cellulitis W MCC
Skin Graft &/or Debrid For Skn Ulcer Or Cellulitis W CC
Skin Graft &/or Debrid For Skn Ulcer Or Cellulitis W/O CC/MCC
Skin Graft &/or Debrid Exc For Skin Ulcer Or Cellulitis W MCC
Skin Graft &/or Debrid Exc For Skin Ulcer Or Cellulitis W CC
Skin Graft &/or Debrid Exc For Skin Ulcer Or Cellulitis W/O CC/MCC
Other Skin, Subcut Tiss & Breast Proc W MCC
Other Skin, Subcut Tiss & Breast Proc W CC
Other Skin, Subcut Tiss & Breast Proc W/O CC/MCC
Mastectomy For Malignancy W CC/MCC
Mastectomy For Malignancy W/O CC/MCC
Breast Biopsy, Local Excision & Other Breast Procedures W CC/MCC
Breast Biopsy, Local Excision & Other Breast Procedures W/O CC/MCC
Skin Ulcers W MCC
Skin Ulcers W CC
Skin Ulcers W/O CC/MCC
Major Skin Disorders W MCC
Major Skin Disorders W/O MCC
Malignant Breast Disorders W MCC
Malignant Breast Disorders W CC
Transfer
ALOS
6.7
4.7
3.0
4.8
2.5
4.4
3.0
3.5
2.2
4.7
3.0
5.1
4.9
3.3
4.7
2.1
5.3
3.9
2.3
9.5
6.3
4.1
8.2
4.1
2.9
6.8
4.5
2.1
2.0
1.7
3.7
1.7
5.8
4.6
3.8
5.2
3.2
5.4
4.0
12 of 20
DRG
Relative
Weight
2.3450
1.0883
0.5787
2.0683
0.9025
1.2571
0.6205
1.0322
0.8978
1.4794
0.6646
1.3585
0.7840
0.5321
1.3361
0.8621
1.8327
0.9632
0.6248
2.8685
1.7010
1.6294
4.0863
1.7705
1.5269
2.6627
2.0192
1.1386
1.0981
1.0285
1.6414
1.0092
1.4559
0.8974
0.5992
1.5371
0.7075
1.3838
0.8997
DRG
Daily
Rate
1,515
1,000
841
1,865
1,538
1,228
889
1,288
1,775
1,368
969
1,158
695
709
1,220
1,786
1,497
1,077
1,166
1,311
1,173
1,742
2,157
1,860
2,303
1,688
1,934
2,336
2,377
2,574
1,920
2,632
1,081
848
677
1,290
948
1,116
986
Day
Outlier
Limit
18
16
11
13
8
16
25
12
9
17
8
27
24
20
15
7
15
14
9
38
24
10
21
33
6
21
17
7
6
4
13
5
18
13
35
14
9
15
45
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
52,057
30,962
17,370
17,638
10,524
41,666
18,560
37,616
11,405
73,998
18,784
60,280
24,914
17,714
41,599
9,887
42,117
29,320
16,964
82,388
54,402
12,577
85,838
135,975
10,268
95,899
23,445
10,933
31,380
26,609
43,028
21,989
46,006
26,642
16,631
43,003
21,019
38,979
37,517
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
599
600
601
602
603
604
605
606
607
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
637
638
639
640
641
642
643
644
645
652
653
654
655
Malignant Breast Disorders W/O CC/MCC
Non-malignant Breast Disorders W CC/MCC
Non-malignant Breast Disorders W/O CC/MCC
Cellulitis W MCC
Cellulitis W/O MCC
Trauma To The Skin, Subcut Tiss & Breast W MCC
Trauma To The Skin, Subcut Tiss & Breast W/O MCC
Minor Skin Disorders W MCC
Minor Skin Disorders W/O MCC
Adrenal & Pituitary Procedures W CC/MCC
Adrenal & Pituitary Procedures W/O CC/MCC
Amputat Of Lower Limb For Endocrine, Nutrit & Metabol Dis W MCC
Amputat Of Lower Limb For Endocrine, Nutrit & Metabol Dis W CC
Amputat Of Lower Limb For Endocrine, Nutrit & Metabol Dis W/O CC/MCC
O.R. Procedures For Obesity W MCC
O.R. Procedures For Obesity W CC
O.R. Procedures For Obesity W/O CC/MCC
Skin Grafts & Wound Debrid For Endoc, Nutrit & Metab Dis W MCC
Skin Grafts & Wound Debrid For Endoc, Nutrit & Metab Dis W CC
Skin Grafts & Wound Debrid For Endoc, Nutrit & Metab Dis W/O CC/MCC
Thyroid, Parathyroid & Thyroglossal Procedures W MCC
Thyroid, Parathyroid & Thyroglossal Procedures W CC
Thyroid, Parathyroid & Thyroglossal Procedures W/O CC/MCC
Other Endocrine, Nutrit & Metab O.R. Proc W MCC
Other Endocrine, Nutrit & Metab O.R. Proc W CC
Other Endocrine, Nutrit & Metab O.R. Proc W/O CC/MCC
Diabetes W MCC
Diabetes W CC
Diabetes W/O CC/MCC
Nutritional & Misc Metabolic Disorders W MCC
Nutritional & Misc Metabolic Disorders W/O MCC
Inborn Errors Of Metabolism
Endocrine Disorders W MCC
Endocrine Disorders W CC
Endocrine Disorders W/O CC/MCC
Kidney Transplant
Major Bladder Procedures W MCC
Major Bladder Procedures W CC
Major Bladder Procedures W/O CC/MCC
Transfer
ALOS
2.6
3.9
2.6
5.5
3.3
2.1
2.0
3.9
2.4
4.6
3.0
11.0
6.7
5.0
5.0
2.9
2.1
11.3
6.4
5.3
4.7
2.2
1.3
8.2
6.1
3.1
3.3
3.0
2.3
3.1
2.2
3.0
4.7
3.1
2.7
5.9
12.6
8.2
5.0
13 of 20
DRG
Relative
Weight
0.7421
0.7020
0.5076
1.9048
1.0860
0.8847
0.6355
0.9611
0.4865
2.9220
2.1470
3.6832
2.1124
1.5462
4.3588
2.0335
1.9507
5.1429
1.8696
1.1746
2.7219
1.3868
0.8940
4.0550
2.1565
1.5887
1.5366
1.1392
0.8566
1.2060
0.7119
1.1990
1.5527
1.1433
0.9736
8.1288
6.2223
3.4717
2.3463
DRG
Daily
Rate
1,236
783
852
1,510
1,429
1,807
1,362
1,070
892
2,726
3,129
1,456
1,373
1,339
3,774
3,057
4,040
1,970
1,261
967
2,507
2,754
2,888
2,149
1,543
2,197
2,022
1,633
1,648
1,712
1,414
1,707
1,430
1,612
1,538
5,995
2,133
1,826
2,048
Day
Outlier
Limit
10
9
6
18
10
5
7
15
8
13
8
36
19
14
14
8
5
26
22
13
14
9
4
32
17
13
10
9
6
10
8
16
17
9
7
21
41
18
12
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
20,962
16,613
11,917
28,228
12,885
6,799
18,662
33,135
15,080
82,230
47,897
97,484
63,698
36,560
91,126
46,739
37,935
106,335
60,702
27,342
59,369
35,793
20,975
129,309
57,747
50,521
20,377
13,351
8,250
15,238
9,384
63,927
56,438
12,050
9,477
183,637
181,345
77,038
55,581
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
Kidney & Ureter Procedures For Neoplasm W MCC
Kidney & Ureter Procedures For Neoplasm W CC
Kidney & Ureter Procedures For Neoplasm W/O CC/MCC
Kidney & Ureter Procedures For Non-neoplasm W MCC
Kidney & Ureter Procedures For Non-neoplasm W CC
Kidney & Ureter Procedures For Non-neoplasm W/O CC/MCC
Minor Bladder Procedures W MCC
Minor Bladder Procedures W CC
Minor Bladder Procedures W/O CC/MCC
Prostatectomy W MCC
Prostatectomy W CC
Prostatectomy W/O CC/MCC
Transurethral Procedures W MCC
Transurethral Procedures W CC
Transurethral Procedures W/O CC/MCC
Urethral Procedures W CC/MCC
Urethral Procedures W/O CC/MCC
Other Kidney & Urinary Tract Procedures W MCC
Other Kidney & Urinary Tract Procedures W CC
Other Kidney & Urinary Tract Procedures W/O CC/MCC
Renal Failure W MCC
Renal Failure W CC
Renal Failure W/O CC/MCC
Admit For Renal Dialysis
Kidney & Urinary Tract Neoplasms W MCC
Kidney & Urinary Tract Neoplasms W CC
Kidney & Urinary Tract Neoplasms W/O CC/MCC
Kidney & Urinary Tract Infections W MCC
Kidney & Urinary Tract Infections W/O MCC
Urinary Stones W Esw Lithotripsy W CC/MCC
Urinary Stones W Esw Lithotripsy W/O CC/MCC
Urinary Stones W/O Esw Lithotripsy W MCC
Urinary Stones W/O Esw Lithotripsy W/O MCC
Kidney & Urinary Tract Signs & Symptoms W MCC
Kidney & Urinary Tract Signs & Symptoms W/O MCC
Urethral Stricture
Other Kidney & Urinary Tract Diagnoses W MCC
Other Kidney & Urinary Tract Diagnoses W CC
Other Kidney & Urinary Tract Diagnoses W/O CC/MCC
Transfer
ALOS
7.9
4.7
3.6
6.8
3.6
2.9
7.1
3.5
1.4
7.2
5.0
2.3
8.5
2.1
2.0
3.9
1.9
6.9
4.0
1.7
5.3
4.0
2.8
2.2
5.3
3.9
2.4
3.5
2.7
2.3
1.7
3.5
2.1
3.5
2.4
2.5
7.2
3.7
2.4
14 of 20
DRG
Relative
Weight
3.5101
2.0619
1.8721
3.6900
1.8855
1.4366
2.4630
1.4360
0.9706
2.1820
1.5899
0.8552
3.4997
1.2501
0.8329
1.2475
0.9512
3.4373
2.1234
1.4959
2.5256
1.5146
1.0573
0.9952
1.5693
1.1282
0.6213
1.3410
0.9294
1.2038
0.9706
1.3355
0.8447
1.0351
0.5666
0.9901
2.5726
1.3066
0.7894
DRG
Daily
Rate
1,931
1,899
2,226
2,363
2,299
2,144
1,500
1,781
2,938
1,316
1,374
1,617
1,774
2,553
1,776
1,399
2,214
2,153
2,287
3,925
2,051
1,635
1,664
1,923
1,289
1,243
1,116
1,649
1,518
2,227
2,516
1,671
1,725
1,280
1,022
1,714
1,545
1,516
1,430
Day
Outlier
Limit
16
11
7
38
15
6
23
12
3
19
15
8
15
8
5
13
7
25
16
7
20
21
7
7
16
16
7
11
9
18
4
11
7
11
8
10
18
10
6
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
26,021
47,982
13,776
180,098
59,445
11,089
78,519
46,658
5,722
47,241
41,056
23,097
25,411
25,635
8,563
33,720
23,083
38,822
60,654
36,413
32,648
20,976
11,262
24,620
42,085
38,625
18,560
15,825
11,619
54,883
19,581
38,767
8,041
31,626
17,204
25,771
25,760
13,868
6,101
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
707
708
709
710
711
712
713
714
715
716
717
718
722
723
724
725
726
727
728
729
730
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
754
Major Male Pelvic Procedures W CC/MCC
Major Male Pelvic Procedures W/O CC/MCC
Penis Procedures W CC/MCC
Penis Procedures W/O CC/MCC
Testes Procedures W CC/MCC
Testes Procedures W/O CC/MCC
Transurethral Prostatectomy W CC/MCC
Transurethral Prostatectomy W/O CC/MCC
Other Male Reproductive System O.R. Proc For Malignancy W CC/MCC
Other Male Reproductive System O.R. Proc For Malignancy W/O CC/MCC
Other Male Reproductive System O.R. Proc Exc Malignancy W CC/MCC
Other Male Reproductive System O.R. Proc Exc Malignancy W/O CC/MCC
Malignancy, Male Reproductive System W MCC
Malignancy, Male Reproductive System W CC
Malignancy, Male Reproductive System W/O CC/MCC
Benign Prostatic Hypertrophy W MCC
Benign Prostatic Hypertrophy W/O MCC
Inflammation Of The Male Reproductive System W MCC
Inflammation Of The Male Reproductive System W/O MCC
Other Male Reproductive System Diagnoses W CC/MCC
Other Male Reproductive System Diagnoses W/O CC/MCC
Pelvic Evisceration, Rad Hysterectomy & Rad Vulvectomy W CC/MCC
Pelvic Evisceration, Rad Hysterectomy & Rad Vulvectomy W/O CC/MCC
Uterine & Adnexa Proc For Ovarian Or Adnexal Malignancy W MCC
Uterine & Adnexa Proc For Ovarian Or Adnexal Malignancy W CC
Uterine & Adnexa Proc For Ovarian Or Adnexal Malignancy W/O CC/MCC
Uterine,adnexa Proc For Non-Ovarian/Adnexal Malig W MCC
Uterine,adnexa Proc For Non-Ovarian/Adnexal Malig W CC
Uterine,adnexa Proc For Non-Ovarian/Adnexal Malig W/O CC/MCC
Uterine & Adnexa Proc For Non-Malignancy W CC/MCC
Uterine & Adnexa Proc For Non-Malignancy W/O CC/MCC
D&C, Conization, Laparascopy & Tubal Interruption W CC/MCC
D&C, Conization, Laparascopy & Tubal Interruption W/O CC/MCC
Vagina, Cervix & Vulva Procedures W CC/MCC
Vagina, Cervix & Vulva Procedures W/O CC/MCC
Female Reproductive System Reconstructive Procedures
Other Female Reproductive System O.R. Procedures W CC/MCC
Other Female Reproductive System O.R. Procedures W/O CC/MCC
Malignancy, Female Reproductive System W MCC
Transfer
ALOS
3.3
2.0
3.3
1.6
4.7
1.9
3.0
1.7
4.1
2.1
4.8
2.5
5.4
3.3
2.1
4.0
2.5
3.9
2.0
3.7
2.3
4.9
3.0
12.9
5.3
3.3
6.7
4.0
2.0
3.0
2.0
3.1
2.0
3.0
1.7
1.6
5.7
2.6
6.2
15 of 20
DRG
Relative
Weight
1.7407
1.4557
1.5046
1.2975
2.1447
0.7998
1.1177
0.6497
2.1235
1.5203
2.0411
0.8232
1.8198
0.7679
0.7648
0.9421
0.5352
1.0793
0.6720
1.1727
0.7037
2.6753
1.4256
5.7632
2.1191
1.3028
2.9730
1.5570
1.2570
1.4764
1.1568
1.1812
1.1438
1.2365
0.8588
1.0220
2.3366
1.1931
2.2900
DRG
Daily
Rate
2,319
3,135
1,998
3,578
1,967
1,803
1,624
1,674
2,242
3,179
1,841
1,403
1,459
1,010
1,577
1,009
927
1,214
1,477
1,372
1,324
2,368
2,085
1,934
1,724
1,714
1,935
1,694
2,734
2,138
2,542
1,677
2,439
1,761
2,200
2,748
1,768
1,987
1,599
Day
Outlier
Limit
9
5
15
5
20
8
12
4
13
6
14
11
15
12
9
11
18
14
4
12
9
14
5
39
14
7
17
11
4
9
5
12
3
8
4
4
16
7
17
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
44,284
29,478
45,257
30,697
72,279
22,219
48,427
14,382
47,761
29,610
46,161
19,116
41,867
30,590
21,401
24,264
13,050
42,193
5,728
29,314
20,216
84,430
27,808
166,678
50,734
29,081
78,728
41,099
9,243
15,997
9,341
35,461
7,946
32,377
19,099
8,841
74,721
27,912
50,991
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
755
756
757
758
759
760
761
765
766
767
768
769
770
774
775
776
777
778
779
780
781
782
789
790
791
792
793
794
795
799
800
801
802
803
804
808
809
810
811
Malignancy, Female Reproductive System W CC
Malignancy, Female Reproductive System W/O CC/MCC
Infections, Female Reproductive System W MCC
Infections, Female Reproductive System W CC
Infections, Female Reproductive System W/O CC/MCC
Menstrual & Other Female Reproductive System Disorders W CC/MCC
Menstrual & Other Female Reproductive System Disorders W/O CC/MCC
Cesarean Section W CC/MCC
Cesarean Section W/O CC/MCC
Vaginal Delivery W Sterilization &/or D&C
Vaginal Delivery W/O.R. Proc Except Steril &/or D&C
Postpartum & Post Abortion Diagnoses W OR Procedure
Abortion W D&C, Aspiration Curettage Or Hysterotomy
Vaginal Delivery W Complicating Diagnoses
Vaginal Delivery W/O Complicating Diagnoses
Postpartum & Post Abortion Diagnoses W/O O.R. Procedure
Ectopic Pregnancy
Threatened Abortion
Abortion W/O D&C
False Labor
Other Antepartum Diagnoses W Medical Complications
Other Antepartum Diagnoses W/O Medical Complications
Neonates, Died Or Transferred To Another Acute Care Facility
Extreme Immaturity or Respiratory Distress Syndrome, Neonate
Prematurity with Major Problems
Prematurity without Major Problems
Full Term Neonate W Major Problems
Neonate W/Other Significant Problems
Normal Newborn
Splenectomy W MCC
Splenectomy W CC
Splenectomy W/O CC/MCC
Other O.R. Proc Of The Blood & Blood Forming Organs W MCC
Other O.R. Proc Of The Blood & Blood Forming Organs W CC
Other O.R. Proc Of The Blood & Blood Forming Organs W/O CC/MCC
Major Hematol/immun Diag Exc Sickle Cell Crisis & Coagul W MCC
Major Hematol/immun Diag Exc Sickle Cell Crisis & Coagul W CC
Major Hematol/immun Diag Exc Sickle Cell Crisis & Coagul W/O CC/MCC
Red Blood Cell Disorders W MCC
Transfer
ALOS
3.7
2.6
6.5
3.2
1.9
2.1
1.5
3.3
2.6
1.9
2.7
2.8
1.5
2.2
1.7
2.2
1.4
2.0
1.4
1.2
2.2
1.7
1.1
0
0
0
4.2
2.3
1.7
7.9
5.0
2.9
8.8
4.6
2.5
6.9
3.5
2.7
5.5
16 of 20
DRG
Relative
Weight
1.0447
0.6315
2.0905
0.8848
0.5920
0.6960
0.5536
1.1586
0.9401
0.9411
0.7018
1.5993
0.7598
0.7512
0.6262
0.8239
0.8836
0.5969
0.4196
0.1980
0.7211
0.5901
0.3084
0
0
0
1.4884
0.4715
0.2503
3.9527
2.3211
1.6395
4.2311
1.8513
1.1929
2.6341
1.1743
0.8211
2.4358
DRG
Daily
Rate
1,219
1,060
1,392
1,190
1,356
1,449
1,608
1,511
1,596
2,179
1,138
2,499
2,207
1,506
1,614
1,592
2,732
1,298
1,316
720
1,445
1,468
1,271
0
0
0
1,553
884
645
2,161
1,998
2,422
2,081
1,742
2,057
1,657
1,457
1,321
1,903
Day
Outlier
Limit
17
8
17
10
3
8
4
13
4
4
5
12
3
6
4
13
3
9
5
3
11
7
2
0
0
0
22
9
5
24
12
8
22
15
8
15
11
8
21
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
0
0
0
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
35,746
16,008
47,121
26,173
4,300
26,350
16,746
14,325
6,840
7,775
22,535
90,458
6,017
7,439
5,848
17,030
7,590
8,790
17,424
6,464
11,191
6,563
3,360
0
0
0
82,405
8,756
5,631
108,619
69,858
38,523
88,646
50,294
35,953
24,978
48,756
27,886
38,861
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
0
0
0
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
812
813
814
815
816
820
821
822
823
824
825
826
827
828
829
830
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
853
854
855
856
857
858
862
Red Blood Cell Disorders W/O MCC
Coagulation Disorders
Reticuloendothelial & Immunity Disorders W MCC
Reticuloendothelial & Immunity Disorders W CC
Reticuloendothelial & Immunity Disorders W/O CC/MCC
Lymphoma & Leukemia W Major O.R. Procedure W MCC
Lymphoma & Leukemia W Major O.R. Procedure W CC
Lymphoma & Leukemia W Major O.R. Procedure W/O CC/MCC
Lymphoma & Non-acute Leukemia W Other O.R. Proc W MCC
Lymphoma & Non-acute Leukemia W Other O.R. Proc W CC
Lymphoma & Non-acute Leukemia W Other O.R. Proc W/O CC/MCC
Myeloprolif Disord Or Poorly Diff Neopl W Maj O.R. Proc W MCC
Myeloprolif Disord Or Poorly Diff Neopl W Maj O.R. Proc W CC
Myeloprolif Disord Or Poorly Diff Neopl W Maj O.R. Proc W/O CC/MCC
Myeloprolif Disord Or Poorly Diff Neopl W Other O.R. Proc W CC/MCC
Myeloprolif Disord Or Poorly Diff Neopl W Other O.R. Proc W/O CC/MCC
Acute Leukemia W/O Major O.R. Procedure W MCC
Acute Leukemia W/O Major O.R. Procedure W CC
Acute Leukemia W/O Major O.R. Procedure W/O CC/MCC
Chemo W Acute Leukemia As SDX Or W High Dose Chemo Agent W MCC
Chemo W Acute Leukemia As SDX W CC Or High Dose Chemo Agent
Chemo W Acute Leukemia As SDX W/O CC/MCC
Lymphoma & Non-acute Leukemia W MCC
Lymphoma & Non-acute Leukemia W CC
Lymphoma & Non-acute Leukemia W/O CC/MCC
Other Myeloprolif Dis Or Poorly Diff Neopl Diag W MCC
Other Myeloprolif Dis Or Poorly Diff Neopl Diag W CC
Other Myeloprolif Dis Or Poorly Diff Neopl Diag W/O CC/MCC
Chemotherapy W/O Acute Leukemia As Secondary Diagnosis W MCC
Chemotherapy W/O Acute Leukemia As Secondary Diagnosis W CC
Chemotherapy W/O Acute Leukemia As Secondary Diagnosis W/O CC/MCC
Radiotherapy
Infectious & Parasitic Diseases W OR Procedure W MCC
Infectious & Parasitic Diseases W OR Procedure W CC
Infectious & Parasitic Diseases W OR Procedure W/O CC/MCC
Postoperative Or Post-Traumatic Infections W OR Proc W MCC
Postoperative Or Post-Traumatic Infections W OR Proc W CC
Postoperative Or Post Traumatic Infections W OR Proc W/O CC/MCC
Postoperative & Post-Traumatic Infections W MCC
Transfer
ALOS
2.9
2.5
4.7
3.4
2.4
17.4
5.0
2.3
11.3
6.6
3.5
11.6
5.4
3.3
6.8
3.0
10.3
7.5
4.0
12.3
5.1
3.4
6.9
4.7
3.1
5.4
4.4
2.9
4.2
3.9
2.6
5.1
17.1
8.5
5.3
10.6
5.7
4.4
5.3
17 of 20
DRG
Relative
Weight
1.0637
1.1746
1.6173
1.0344
0.6726
8.2055
2.5440
1.4257
5.2044
2.6562
1.6270
5.6833
2.5083
1.8348
3.6966
1.4812
5.7772
3.5739
1.6457
6.5938
3.1049
1.0823
2.6785
1.7441
1.0215
1.7987
1.2534
0.7033
2.5328
1.4523
1.0821
1.4646
10.0846
2.7664
2.2488
4.5449
1.9721
1.3899
1.6822
DRG
Daily
Rate
1,588
2,075
1,490
1,325
1,218
2,038
2,207
2,672
1,987
1,732
2,036
2,125
2,018
2,378
2,357
2,166
2,435
2,052
1,795
2,323
2,641
1,394
1,685
1,600
1,422
1,450
1,228
1,061
2,592
1,633
1,816
1,253
2,552
1,416
1,830
1,854
1,490
1,383
1,374
Day
Outlier
Limit
9
6
17
11
7
55
16
8
41
22
12
34
18
10
31
12
52
34
16
43
21
8
26
13
10
17
18
14
5
8
6
23
66
31
15
37
19
14
16
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
12,242
14,661
90,529
34,205
18,764
260,352
64,348
38,567
193,767
73,533
51,456
141,646
61,933
38,945
146,139
42,478
215,000
138,511
59,767
193,284
112,293
37,521
110,269
15,996
34,013
44,117
41,180
22,213
8,338
17,446
28,727
45,208
142,053
96,106
48,770
152,995
66,438
42,966
56,252
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
863
864
865
866
867
868
869
870
871
872
876
880
881
882
883
884
885
886
887
894
895
896
897
901
902
903
904
905
906
907
908
909
913
914
915
916
917
918
919
Postoperative & Post-Traumatic Infections W/O MCC
Fever Of Unknown Origin
Viral Illness W MCC
Viral Illness W/O MCC
Other Infectious & Parasitic Diseases Diagnoses W MCC
Other Infectious & Parasitic Diseases Diagnoses W CC
Other Infectious & Parasitic Diseases Diagnoses W/O CC/MCC
Septicemia W MV 96+ Hours
Septicemia W/O MV 96+ Hours W MCC
Septicemia W/O MV 96+ Hours W/O MCC
O.R. Procedure W Principal Diagnoses Of Mental Illness
Acute Adjustment Reaction & Psychosocial Dysfunction
Depressive Neuroses
Neuroses Except Depressive
Disorders Of Personality & Impulse Control
Organic Disturbances & Mental Retardation
Psychoses
Behavioral & Developmental Disorders
Other Mental Disorder Diagnoses
Alcohol/drug Abuse Or Dependence, Left AMA
Alcohol/drug Abuse Or Dependence W Rehabilitation Therapy
Alcohol/drug Abuse Or Dependence W/O Rehabilitation Therapy W MCC
Alcohol/drug Abuse Or Dependence W/O Rehabilitation Therapy W/O MCC
Wound Debridements For Injuries W MCC
Wound Debridements For Injuries W CC
Wound Debridements For Injuries W/O CC/MCC
Skin Grafts For Injuries W CC/MCC
Skin Grafts For Injuries W/O CC/MCC
Hand Procedures For Injuries
Other O.R. Procedures For Injuries W MCC
Other O.R. Procedures For Injuries W CC
Other O.R. Procedures For Injuries W/O CC/MCC
Traumatic Injury W MCC
Traumatic Injury W/O MCC
Allergic Reactions W MCC
Allergic Reactions W/O MCC
Poisoning & Toxic Effects Of Drugs W MCC
Poisoning & Toxic Effects Of Drugs W/O MCC
Complications Of Treatment W MCC
Transfer
ALOS
4.0
2.4
4.2
2.1
6.2
4.1
2.8
12.2
5.8
4.6
6.3
3.2
3.5
3.5
3.8
4.7
4.2
4.3
2.4
1.7
14.6
4.0
2.8
10.0
4.7
2.5
7.0
3.6
2.0
7.1
4.5
3.0
3.4
1.9
2.9
1.5
2.9
1.5
4.0
18 of 20
DRG
Relative
Weight
1.2778
0.8413
1.4003
0.6394
2.4834
1.0049
0.7224
7.1969
3.0510
1.7836
1.5940
0.9520
0.7450
0.7879
0.8803
0.7601
0.8461
0.9699
0.4965
0.3556
2.0531
1.2765
0.6190
4.9312
1.7226
0.8699
3.2941
1.4004
1.0888
2.1943
1.9758
1.2526
1.3738
0.6600
1.4944
0.4263
1.5421
0.6522
1.6711
DRG
Daily
Rate
1,383
1,524
1,440
1,306
1,726
1,058
1,121
2,550
2,281
1,664
1,102
1,284
919
986
1,011
703
883
972
881
927
608
1,368
964
2,135
1,587
1,537
2,043
1,693
2,357
1,332
1,905
1,801
1,754
1,496
2,208
1,198
2,278
1,921
1,800
Day
Outlier
Limit
11
7
14
6
23
15
13
30
28
20
16
16
8
9
11
18
12
9
11
8
48
14
8
24
22
3
26
14
10
41
18
9
14
7
20
5
10
4
21
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
15,238
10,848
51,192
8,423
97,584
35,926
32,661
65,395
43,610
28,882
39,536
17,517
6,917
7,945
9,186
23,170
10,558
8,768
15,152
14,760
53,106
45,670
6,957
102,229
76,860
5,268
112,584
40,231
52,559
29,211
66,876
11,304
35,513
21,962
81,256
14,297
21,104
7,161
80,382
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
920
921
922
923
927
928
929
933
934
935
939
940
941
945
946
947
948
949
950
951
955
956
957
958
959
963
964
965
969
970
974
975
976
977
981
982
983
984
985
Complications Of Treatment W CC
Complications Of Treatment W/O CC/MCC
Other Injury, Poisoning & Toxic Effect Diag W MCC
Other Injury, Poisoning & Toxic Effect Diag W/O MCC
Extensive Burns Or Full Thickness Burns W MV 96+ Hrs W Skin Graft
Full Thickness Burn W Skin Graft Or Inhal Inj W CC/MCC
Full Thickness Burn W Skin Graft Or Inhal Inj W/O CC/MCC
Extensive Burns Or Full Thickness Burns W MV 96+ Hrs W/O Skin Graft
Full Thickness Burn W/O Skin Grft Or Inhal Inj
Non-Extensive Burns
O.R. Proc W Diagnoses Of Other Contact W Health Services W MCC
O.R. Proc W Diagnoses Of Other Contact W Health Services W CC
O.R. Proc W Diagnoses Of Other Contact W Health Services W/O CC/MCC
Rehabilitation W CC/MCC
Rehabilitation W/O CC/MCC
Signs & Symptoms W MCC
Signs & Symptoms W/O MCC
Aftercare W CC/MCC
Aftercare W/O CC/MCC
Other Factors Influencing Health Status
Craniotomy For Multiple Significant Trauma
Limb Reattachment, Hip & Femur Proc For Multiple Significant Trauma
Other O.R. Procedures For Multiple Significant Trauma W MCC
Other O.R. Procedures For Multiple Significant Trauma W CC
Other O.R. Procedures For Multiple Significant Trauma W/O CC/MCC
Other Multiple Significant Trauma W MCC
Other Multiple Significant Trauma W CC
Other Multiple Significant Trauma W/O CC/MCC
HIV W Extensive O.R. Procedure W MCC
HIV W Extensive O.R. Procedure W/O MCC
HIV W Major Related Condition W MCC
HIV W Major Related Condition W CC
HIV W Major Related Condition W/O CC/MCC
HIV W/OR W/O Other Related Condition
Extensive O.R. Procedure Unrelated To Principal Diagnosis W MCC
Extensive O.R. Procedure Unrelated To Principal Diagnosis W CC
Extensive O.R. Procedure Unrelated To Principal Diagnosis W/O CC/MCC
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W MCC
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W CC
Transfer
ALOS
2.9
2.1
4.0
2.3
23.9
11.1
6.9
2.4
3.5
3.1
17.8
10.6
2.8
12.1
10.1
3.6
2.6
7.2
5.1
1.6
9.3
8.1
11.1
10.4
5.9
6.0
5.1
3.3
13.2
6.1
5.7
4.9
3.5
3.7
9.6
5.3
2.2
14.0
7.4
19 of 20
DRG
Relative
Weight
0.9222
0.5652
2.1396
1.0747
15.2041
4.2136
2.7705
2.8072
0.9118
0.9331
3.9239
2.4549
1.4484
3.2320
2.5989
0.9623
0.9466
0.7725
0.4692
0.2930
9.2199
5.6783
7.9794
4.9298
3.8526
4.0621
2.1248
1.5154
6.6983
3.1169
2.8921
1.5003
0.9959
1.1358
5.6511
3.1554
1.0710
4.3234
2.2438
DRG
Daily
Rate
1,358
1,160
2,310
1,997
2,754
1,648
1,733
5,063
1,125
1,320
954
1,004
2,231
1,157
1,114
1,148
1,607
466
399
778
4,292
3,054
3,120
2,054
2,841
2,950
1,800
1,976
2,197
2,212
2,196
1,325
1,225
1,343
2,562
2,563
2,117
1,333
1,307
Day
Outlier
Limit
10
8
59
8
50
25
22
10
13
11
53
33
19
36
28
12
8
39
28
15
27
25
38
24
17
23
14
9
30
17
17
17
11
13
38
21
6
43
21
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
8,973
17,732
85,202
13,493
376,859
113,484
94,956
61,023
30,920
38,678
118,736
59,353
41,381
37,948
29,924
30,792
11,885
30,824
15,877
18,307
246,098
193,380
73,080
38,280
103,171
114,087
52,686
37,434
136,510
67,031
34,534
43,874
30,046
39,003
75,045
35,393
14,028
107,196
58,947
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
Kansas 2010 DRG Weights and Limits
Effective October 1, 2009
DRG
986
987
988
989
993*
994*
995*
996*
997*
998
999
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O CC/MCC
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W MCC
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W CC
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W/O CC/MCC
Neonates, < 1,000 Grams
Neonates, 1,000-1,400 Grams
Neonates, 1,500-1,999 Grams
Neonates,> 2,000 Grams w/ RDS
Neonates, > 2,000 Grams, Premature w/Major Problems
Principal Diagnosis Invalid As Discharge Diagnosis
Ungroupable
Transfer
ALOS
3.0
8.9
5.6
2.4
45.8
34.0
16.1
9.5
9.2
0.0
0.0
* State-created neonatal DRGs
20 of 20
DRG
Relative
Weight
1.0877
3.7745
2.5321
1.1810
19.1045
10.1087
4.6325
4.0192
2.5949
0.0000
0.0000
DRG
Daily
Rate
1,575
1,840
1,975
2,130
1,805
1,287
1,243
1,839
1,217
Day
Outlier
Limit
10
33
18
5
138
86
50
55
36
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
Cost
Outlier
Limit
27,911
150,229
27,287
8,090
181,138
105,665
58,067
88,998
38,763
Cost
Outlier
Adj. %
75
75
75
75
75
75
75
75
75
Hospital Rates
Effective October 1, 2009
Hospital
CCR from Cost
Report Period
Rate
Peer Group 1
Meadowbrook Rehabilitation
Kaw Valley
Providence Medical Center
Select Specialty Hospital Overland Park
Doctors Specialty Hospital LLC
Kansas City Orthopedic
Olathe Medical Center
Children's Mercy Hospital South
Heartland Spine & Specialty Hospital
Marillac Center Inc
Menorah Medical Center
Mid-America Rehab Hospital
Overland Park Regional Medical Center
Saint Lukes South Hospital, Inc.
Specialty Hospital of Mid America
Shawnee Mission Medical Center, Inc.
Kansas Rehabilitation Hospital
Saint Francis Health Center
Select Specialty Hospital Topeka
Stormont Vail Regional Health Center
Galichia Heart Hospital LLC
Kansas Heart Hospital LLC
Kansas Spine Hospital
Kansas Surgery & Recovery Center
Select Specialty Hospital Wichita In
Vi Ch
Via
Christi
i ti R
Regional
i
lM
Medical
di l C
Center
t
Via Christi Rehabilitation Center
Wesley Medical Center
Wesley Rehabilitation Center
Wichita Specialty Hospital
GARDNER
KANSAS CITY
KANSAS CITY
KANSAS CITY
LEAWOOD
LEAWOOD
OLATHE
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
OVERLAND PARK
SHAWNEE MISSION
TOPEKA
TOPEKA
TOPEKA
TOPEKA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
WICHITA
0.3996
0.3838
0.3836
0.3822
0.2042
0.2258
0.3977
0.5569
0.3388
0.3838
0.3031
0.4945
0.1929
0.3369
0.4105
0.2255
0.5966
0.3940
0.4472
0.2764
0.3845
0.3870
0.2752
0.5100
0.3765
0 2734
0.2734
0.3979
0.2358
0.5283
0.6239
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4,300
4 300
4,300
4,300
4,300
4,300
4,300
Kansas Medical Center LLC
Sumner County Hospital District #1
Susan B. Allen Memorial Hospital
Hays Medical Center, Inc.
Holton Community Hospital
Hutchinson Hospital Corporation
Summit Surgical LLC
Geary Community Hospital
Lawrence Memorial Hospital
Cushing Memorial Hospital
Saint John Hospital
Manhattan Surgical Hospital
Mercy Regional Health Center of Manhattan
Newton Medical Center
Prairie View Hospital
Community Hospital Onaga, Inc.
Ransom Memorial Hospital
Miami County Medical Center
Mt. Carmel Medical Center
Salina Regional Health Center
Salina Surgical Hospital
Wamego City Hospital
Sumner Regional Medical Center
Jefferson County Memorial Hospital
ANDOVER
CALDWELL
EL DORADO
HAYS
HOLTON
HUTCHINSON
HUTCHINSON
JUNCTION CITY
LAWRENCE
LEAVENWORTH
LEAVENWORTH
MANHATTAN
MANHATTAN
NEWTON
NEWTON
ONAGA
OTTAWA
PAOLA
PITTSBURG
SALINA
SALINA
WAMEGO
WELLINGTON
WINCHESTER
0.5257
1.0000
0.5336
0.3537
0.5611
0.4676
0.6652
0.4060
0.4231
0.3955
0.4129
0.2737
0.4389
0.4300
1.0000
0.7360
0.5711
0.4561
0.3645
0.4153
0.3992
0.6598
0.5190
0.9306
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
4,784
Peer Group 2
1
Hospital Rates
Effective October 1, 2009
Hospital
CCR from Cost
Report Period
Rate
0.5420
0.7018
0.5698
1.0000
0.5077
1.0000
0.8371
0.5871
0.6192
0.4310
0.6817
0.5335
0.4956
1.0000
0.8134
0.5746
0.7854
1.0000
0.3900
0.5753
1.0000
0.7557
0.6235
0.7514
0.3222
0 5726
0.5726
0.4002
0.7087
0.4574
0.8295
0.4181
0.3424
1.0000
0.9015
0.6572
0.7758
0.7861
0.8919
0.7795
0.8336
0.6258
0.9571
1.0000
0.3481
0.4758
0.7960
0.9974
0.4985
0.8383
0.8754
1.0000
0.9527
0.5913
1.0000
0.5222
0.7746
0.5743
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4 106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
Peer Group 3
Memorial Hospital
Hospital District No. 6 of Harper Co (Anthony Medical Ctr)
South Central Kansas Regional Med Center
Ashland Health Center
Atchison Hospital Association
Rawlins County Health Center
Republic County Hospital
Mitchell County Hospital
Coffey County Hospital
Neosho Memorial Regional Medical Center
Clay County Medical Center
Coffeyville Regional Medical Center
Citizens Medical Center
Comanche County Hospital
Maude Norton Memorial Hospital
Cloud County Health Center
Morris County Hospital
Lane County Hospital
Western Plains Medical Complex
Morton County Hospital
Ellinwood District Hospital
Ellsworth County Medical Center
Newman Memorial County Hospital
Greenwood County Hospital
Mercy Health Systems - Fort Scott
F d i R
Fredonia
Regional
i
lH
Hospital
it l
Saint Catherine Hospital
Anderson County Hospital
Hospital District #1 Crawford County
Goodland Regional Medical Center
Central Kansas Medical Center
Surgical & Diagnostic Center of Great Bend
Great Plains of Kiowa County, Inc.
Hanover Hospital (Washington County)
Harper County Hospital District #5
Herington Municipal Hospital
Hiawatha Community Hospital
Graham County Hospital
Hillsboro Community Health Center
Clara Barton Hospital Association
Horton Community Hospital
Sheridan County Health Complex
Stevens County Hospital
Mercy Health Systems - Independence
Allen County Hospital
Hodgeman County Health Center
Stanton County Hospital
Ninnescah Valley Health Systems-Kingman
Edwards County Hospital
Kiowa District Hospital
Rush County Memorial Hospital
Kearny County Hospital
Saint Joseph Medical Center
Wichita County Health Center
Southwest Medical Center
Lincoln County Hospital
Lindsborg Community Hospital
ABILENE
ANTHONY
ARKANSAS CITY
ASHLAND
ATCHISON
ATWOOD
BELLEVILLE
BELOIT
BURLINGTON
CHANUTE
CLAY CENTER
COFFEYVILLE
COLBY
COLDWATER
COLUMBUS
CONCORDIA
COUNCIL GROVE
DIGHTON
DODGE CITY
ELKHART
ELLINWOOD
ELLSWORTH
EMPORIA
EUREKA
FORT SCOTT
FREDONIA
GARDEN CITY
GARNETT
GIRARD
GOODLAND
GREAT BEND
GREAT BEND
GREENSBURG
HANOVER
HARPER
HERINGTON
HIAWATHA
HILL CITY
HILLSBORO
HOISINGTON
HORTON
HOXIE
HUGOTON
INDEPENDENCE
IOLA
JETMORE
JOHNSON
KINGMAN
KINSLEY
KIOWA
LACROSSE
LAKIN
LARNED
LEOTI
LIBERAL
LINCOLN
LINDSBORG
2
Hospital Rates
Effective October 1, 2009
Hospital
CCR from Cost
Report Period
Rate
Peer Group 3 (continued)
Hospital District #1 Rice County
Jewell County Hospital
Saint Luke Hospital
Community Memorial Healthcare
Memorial Hospital - McPherson
Meade District Hospital
Medicine Lodge Memorial Hospital
Great Plains of Ottawa County, Inc.
Minneola District Hospital
Mercy Hospital - Moundridge
Wilson County Hospital
Ness County Hospital District #2
Norton County Hospital
Logan County Hospital
Decatur County Hospital
Osborne County Memorial Hospital
Oswego Medical Center LLC
Labette County Medical Center
Great Plains of Phillips County, Inc.
Rooks County Health Center
Pratt Regional Medical Center
Gove County Medical Center
Grisell Memorial Hospital District #1
Russell Regional Hospital
Great Plains of Sabetha, Inc.
S t t District
Satanta
Di t i t Hospital
H
it l
Scott County Hospital, Inc.
Sedan City Hospital
Nemaha Valley Community Hospital
Great Plains of Smith County, Inc.
Great Plains of Cheyenne County, Inc.
Stafford District Hospital #4
Hamilton County Hospital
Great Plains of Greeley County, Inc.
Bob Wilson Memorial Hospital
Trego County Lemke Memorial Hospital
Washington County Hospital
William Newton Memorial Hospital
LYONS
MANKATO
MARION
MARYSVILLE
MCPHERSON
MEADE
MEDICINE LODGE
MINNEAPOLIS
MINNEOLA
MOUNDRIDGE
NEODESHA
NESS CITY
NORTON
OAKLEY
OBERLIN
OSBORNE
OSWEGO
PARSONS
PHILLIPSBURG
PLAINVILLE
PRATT
QUINTER
RANSOM
RUSSELL
SABETHA
SATANTA
SCOTT CITY
SEDAN
SENECA
SMITH CENTER
ST FRANCIS
STAFFORD
SYRACUSE
TRIBUNE
ULYSSES
WAKEENEY
WASHINGTON
WINFIELD
1.0000
1.0000
0.7373
0.5376
0.5487
0.7283
0.8082
1.0000
0.6622
0.7074
1.0000
0.8686
0.9945
0.7085
0.8241
1.0000
0.5673
0.5036
0.9543
1.0000
0.5991
0.8009
1.0000
0.6988
0.7627
1 0000
1.0000
0.6985
1.0000
0.6671
0.9499
1.0000
1.0000
1.0000
0.6880
1.0000
0.5677
0.9098
0.7138
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4 106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
4,106
Ave. Peer Group 2 w/o Prov. Assessment
Out of State
0.5007
3,803
3