For purposes of Chapter 5160-2 of the
Administrative Code, the following definitions apply, unless the context
clearly indicates otherwise:
(A)
"Diagnosis related groups (DRGs)" - a patient
classification system that reflects clinically cohesive groupings of services
that consume similar amounts of hospital resources in an inpatient setting. The
groupings used to assign cases to a DRG for claims payment and the grouping
logic used to develop relative weights for DRG's are described in rule
5160-2-65
of the Administrative Code.
(B)
"Discharged" - a
patient who:
(1)
Is formally released from a hospital;
(2)
Dies while
hospitalized;
(3)
Is discharged within the same hospital from an acute
care bed and admitted to a bed in an inpatient psychiatric facility or is
discharged within the same hospital from a bed in an inpatient psychiatric
facility to an acute care bed. Rule
5160-2-65
of the Administrative Code explains the payment methodology for these types of
a discharges; or
(4)
Signs himself or herself out against medical advice
(AMA).
(C)
"Enhanced Ambulatory Patient Groups (EAPGs)" - a group
of outpatient procedures, encounters, or ancillary services, which reflect
similar patient characteristics and resource utilization and which incorporate
the use of "International Classification of Diseases" diagnosis codes, current
procedural terminology (CPT) code set and healthcare common procedure coding
system (HCPCS) procedure codes.
(D)
"Hospital" - has
the same meaning as in rule
5160-2-01 of
the Administrative Code.
(E)
"Inpatient" - a patient who is admitted to a hospital
based upon the written orders of a practitioner of physician services as
described in paragraph (L) of this rule and whose inpatient stay continues
beyond midnight of the day of admission.
(F)
"Inpatient
psychiatric facility" or "distinct part psychiatric unit" - a hospital or an
unit of a hospital that focuses on the treatment of the behavioral health needs
of a patient and is excluded from the medicare inpatient prospective payment
system in accordance with
42 C.F.R.
412.25 effective as of October 1,
2020.
(G)
"Inpatient services" - services which are ordinarily
furnished in a hospital for the care and treatment of patients. Inpatient
services include all covered services provided to patients during the course of
their inpatient stay, whether furnished directly by the hospital or under
arrangement, except for direct-care services provided by a practitioner of
physician services as defined in paragraph (L) of this rule. Emergency room
services are covered as an inpatient service when a patient is admitted from
the emergency room.
Outpatient services provided within
three calendar days prior to the date of admission in hospitals will be covered
as inpatient services. This provision applies when the patient recieves all of
the services, including emergency room and observation services, at the same
hospital. The following exceptions apply:
(1)
When a patient's
medicaid coverage changes payer sources (fee-for-service or managed care) on
the date of the inpatient admission, all outpatient services provided within
three calendar days prior to the inpatient admission will be submitted to the
payer source responsible for those dates of service. The inpatient claim will
be submitted to the payer source in effect on the date of
admission.
(2)
When a patient is admitted under the inpatient hospital
services program (IHSP) benefit plan, all outpatient services provided by
either the same hospital or different hospital, prior to the inpatient
admission will not be included on the inpatient claim, with the exception of
any outpatient services provided on the date of admission which will be
included on the inpatient hospital claim if provided at the same facility as
the inpatient admission.
(3)
When outpatient behavioral health services as described
in rule 5160-2-76 of the Administrative Code are provided, any outpatient
behavioral health services provided within three calendar days prior to the
inpatient admission will be submitted on an outpatient claim.
(H)
"Medically necessary services" - services as defined in rule
5160-1-01
of the Administrative Code.
(I)
"Observation
services" - those services furnished in an outpatient hospital setting,
including use of a bed and periodic monitoring by a hospital's nursing or other
staff, which are reasonable and necessary to evaluate a patient's condition or
determine the need for possible admission to the hospital as an
inpatient.
(J)
"Outpatient" - a patient who is not admitted as an
inpatient and who receives outpatient services at a hospital or at a hospital's
off-site unit which has been extended accreditation by the "Joint Commission,"
the "American Osteopathic Association", or is certified under medicare.
Outpatient includes a patient admitted as an inpatient whose inpatient stay
does not extend beyond midnight of the day of admission except in instances
when, on the day of admission, a patient dies or is transferred to an inpatient
psychiatric facility within the same hospital, to another hospital, or to a
state psychiatric facility.
(K)
"Outpatient
services" - diagnostic, therapeutic, rehabilitative, or palliative treatment or
services furnished by or under the direction of a practitioner of physician
services which are furnished to a patient by a hospital. Outpatient services do
not include direct-care services provided by a practitioner of physician
services as defined in paragraph (L) of this rule.
(L)
"Practitioner of
physician services" - are physicians, podiatrists, dentists, clinical nurse
specialists, certified nurse-midwives, certified nurse practitioners or
physician assistants.
(M)
"Principal diagnosis" - the diagnosis established after
study to be chiefly responsible for causing the patient's admission to the
hospital.
(N)
"Readmission" - an admission to the same institution
within thirty days of discharge for hospitals paid under the Ohio department of
medicaid's prospective payment system, as described in rule
5160-2-65
of the Administrative Code.
(O)
"Transfer" - a
patient who:
(1)
Is moved from one eligible hospital's, inpatient or
outpatient department to another eligible hospital's inpatient or outpatient
department, including state psychiatric facilities;
(2)
Is moved from an
eligible hospital to the same hospital's inpatient psychiatric facility;
or
(3)
Is moved to an eligible hospital from the same
hospital's inpatient psychiatric facility.
Replaces: 5160-2-02
Notes
Ohio Admin. Code
5160-2-02
Effective:
1/1/2022
Five Year Review (FYR) Dates:
01/01/2027
Promulgated
Under:
119.03
Statutory Authority:
5164.02
Rule Amplifies:
5162.03,
5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977,
01/08/1979, 02/01/1980, 10/01/1983 (Emer.), 12/29/1983, 10/01/1984, 11/09/1984
(Emer.), 02/04/1985, 07/29/1985, 07/03/1986, 10/19/1987, 04/23/1988,
07/01/1989, 12/01/1989, 07/01/1990, 09/03/1991 (Emer.), 11/10/1991, 07/01/1992,
07/01/1993, 01/20/1995, 12/29/1995 (Emer.), 03/16/1996, 08/01/2002, 10/01/2003,
06/01/2004, 10/01/2005, 12/06/2010, 04/30/2015,
01/01/2016