SECTION 371.203. TMRP Review Process

(a) The TMRP review process includes:

(1) Admission review to evaluate the medical necessity of the admission. For purposes of the TMRP reviews, medical necessity means the patient has a condition requiring treatment that can be safely provided only in the inpatient setting.

(2) Diagnosis-related group (DRG) validation to confirm documentation in the medical record of the critical elements necessary to assign a DRG. The hospital staff is responsible and held accountable for the accuracy of the required critical elements. Those elements are age, sex, discharge status, admission date, discharge date, principal diagnosis, principal and secondary procedures, any complications or comorbidities (secondary diagnoses), and Present on Admission (POA) indicators.

(A) POA review validates the POA indicator assigned to the principal and secondary diagnoses codes reported on claim forms. If it is determined that the principal and/or secondary diagnoses were not present at the time the order for inpatient admission occurs, HHSC revises the POA indicator for the diagnosis code. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

(B) DRG validation confirms that the principal and secondary diagnoses and procedures are sequenced correctly. The principal diagnosis is the diagnosis (condition) established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The secondary diagnoses are conditions that affect the patient care in terms of requiring: clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care and/or monitoring, or in the case of a newborn, conditions the physician deems to have clinically significant implications for future health care needs. If the principal diagnosis, secondary diagnoses, or procedures are not substantiated in the medical record, are not sequenced correctly, or have been omitted, codes may be deleted, changed, or added.

(C) When the correct diagnosis and procedure coding and sequencing have been determined, the information is entered into the applicable version of the Grouper software for a DRG assignment. CMS-approved DRG Grouper software considers the required critical elements and determines the final DRG assignment. If the DRG validation process results in deletions, changes, or additions to the critical elements and these changes cause the DRG to be reassigned, HHSC directs the claims administrator to adjust the payment to the hospital accordingly.

(3) Quality of care review to assess whether the care provided meets generally accepted standards of medical and hospital care practices or puts the patient at risk of unnecessary injury, disease, or death. Quality of care review includes the use of discharge screens and generic quality screens. If quality of care issues are identified, physician consultants under contract with HHSC and of the specialty related to the care provided determine possible clinical recommendations or corrective actions.

(4) Readmission review to evaluate each admission on its individual merits and determine if the second or subsequent admissions resulted from a premature discharge or were required to provide services that should have been provided in a previous admission.

(5) Day outlier review, which includes DRG validation, verifies the medical necessity of each day of the admission.

(6) Cost outlier review to verify that services billed were medically necessary, ordered by a physician or non-physician provider, rendered and billed appropriately, and substantiated in the medical record.

(b) HHSC reviews the complete medical record for the requested admission(s) to make decisions on all aspects of this review process. The complete medical record may include: emergency room records, medical/surgical history and physical examination, discharge summary, physicians' progress notes, physicians' orders, lab reports, diagnostic and imaging reports, operative reports, pathology reports, nurses' notes, medication sheets, vital signs sheets, therapy notes, specialty consultation reports, and special diagnostic and treatment records. If the complete medical record is not available during the review, HHSC issues a preliminary technical denial and notifies the facility.

(c) A physician consultant under contract with HHSC makes all decisions concerning medical necessity, cause of readmission, and appropriateness of setting for the service provided. In the event the physician consultant determines the services were not medically necessary, should have been provided in a previous admission, or were not provided in the appropriate setting, the claim is denied, and HHSC notifies the hospital in writing. If a hospital claim is denied for lack of medical necessity or for being provided in an inappropriate setting, HHSC considers for denial physician and/or non-physician Medicaid provider claims associated with the hospital admission or service when such claims can be identified and are deemed to be the result of inappropriate admission orders. Physicians and/or non-physician providers are notified in writing if the claim for professional services is denied. The written notification explains the process for appealing the denial.

(d) The OIG conducts training for providers, in a manner and format determined by the OIG, on at least an annual basis to communicate with and educate providers about the DRG validation criteria used by the OIG in conducting hospital utilization reviews and audits as outlined in this section.

Source Note: The provisions of this §371.203 adopted to be effective July 11, 1989, 14 TexReg 3060; amended to be effective February 1, 1991, 16 TexReg 232; amended to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective July 27, 1994, 19 TexReg 5493; amended to be effective November 22, 1995, 20 TexReg 9274; amended to be effective March 25, 1996, 21 TexReg 2079; transferred effective September 1, 1997, as published in the Texas Register February 18,2000, 25 TexReg 1308; amended to beeffective March 30, 2003, 28 TexReg 2481; amended to be effective January 11, 2004, 29 TexReg 357; amended to be effective January 1, 2014, 38 TexReg 9479; amended to be effective May 1, 2016, 41 TexReg 2941