Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

In the matter of the amendment of ARM 37.86.2801, 37.86.2806, 37.86.2820, 37.86.2901, 37.86.2902, 37.86.3001, 37.86.3009, 37.86.3020, 37.86.3101, 37.86.3103, 37.86.3105 pertaining to Medicaid outpatient and inpatient hospital services

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NOTICE OF AMENDMENT

TO: All Concerned Persons

1. On May 8, 2014, the Department of Public Health and Human Services published MAR Notice No. 37-678 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 950 of the 2014 Montana Administrative Register, Issue Number 9.

2. The department has amended ARM 37.86.2806, 37.86.2820, 37.86.2901, 37.86.3009, 37.86.3020, 37.86.3101, and 37.86.3105 as proposed.

3. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:

37.86.2801 ALL HOSPITAL REIMBURSEMENT, GENERAL

(1) through (6)(d) remain as proposed.

(7) Medicaid reimbursement for early elective delivery and nonmedically necessary cesarean sections will not be made unless the hospital submitting the claim meets the following requirements:

(a) remains as proposed.

(b) Effective October 1, 2014, hospital claims for inductions and cesarean sections must meet the following coding requirements:

(i) current ICD~~-10~~ inpatient procedure codes must be used on all inpatient hospital claims; and

(ii) claims for inductions or cesarean sections must have one of the following condition codes:

(A) Condition Code 81–cesarean section or induction performed at less than 30 39 weeks for medical necessity;

(B) through (c)(ii) remain as proposed.

(8) All hospitals must use current ICD procedure codes for ~~both~~ inpatient claims and current CPT codes for outpatient claims, including Medicare crossover claims.

AUTH: 2-4-201, 53-2-201, 53-6-113, MCA

IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

37.86.2902 INPATIENT HOSPITAL SERVICES, REQUIREMENTS

(1) through (8) remain as proposed.

(9) Effective July 1, 2014, all hospitals that perform deliveries must have a hard stop policy regarding early elective deliveries and nonmedically necessary cesarean sections. The policy must have the following parts:

(a) remains as proposed.

(b) confirmation of weeks gestation must be determined by the American Congress of Obstetricians and Gynecologists guidelines. At least one of the following guidelines must be met:

(i) and (ii) remain as proposed.

(iii) an ultrasound prior to 20 weeks gestation that confirms the gestational age of at least 39 weeks~~; and~~.

(c) if pregnancy care was not initiated prior to 20 weeks gestation, the gestational age may be documented from first day of the last menstrual period (LMP); and

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

37.86.3001 OUTPATIENT HOSPITAL SERVICES, DEFINITIONS

(1) through (12) remain as proposed.

(13) "ICD-10-CM" means the International Classification of Diseases, Tenth Revision based on the official version of the World Health Organization's Tenth Revision for diagnosis coding, effective for dates of service or discharge date ~~October 1, 2014~~ October 1, 2015 and thereafter.

(13) through (21) remain as proposed, but are renumbered (14) through (22) as a result of renumbering in MAR Notice No. 37-665, effective 3/14/14.

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

37.86.3103 OUTPATIENT HOSPITAL SERVICES, CARDIAC REHABILITATION SERVICES (1) Cardiac rehabilitation services are limited to

a maximum of two 1-hour sessions per day for up to 36 sessions, limited to the following cardiac events and diagnoses:

(a) through (d) remain as proposed.

(e) percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; ~~and~~

(f) heart valve repair or replacement. ; and

(g) chronic stable heart failure.

AUTH: 53-2-201, 53-6-111, MCA

IMP: 53-2-201, 53-6-101, MCA

4. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

COMMENT #1: Three comments were made in support of the new pulmonary rehabilitation diagnosis changes for procedure code G0424; however, there was a concern of the previous diagnosis being removed for procedure codes G0237, G0238, and G0239.

RESPONSE #1: The department thanks the commenters for their support of the rule changes. The department intended the diagnosis changes to be in effect for procedure code G0424 only as per CMS guidelines; the proposed guidelines do not affect procedure codes G0237, G0238, and G0239.

COMMENT #2: Three comments stated that chronic heart failure should be on the list of allowable conditions for cardiac rehab as it is on the Centers for Medicare and Medicaid Services (CMS) guidelines, and expressed support of the other changes to both cardiac and pulmonary rehabilitation.

RESPONSE #2: Stable chronic heart failure will be added to ARM 37.86.3103 per CMS guidelines. The department thanks the commenter for their support of the rule.

COMMENT #3: One comment stated that pulmonary rehabilitation should not be a covered service, and that cardiac rehab should continue to have a time limit.

RESPONSE #3: The department is following CMS coverage guidelines on both pulmonary and cardiac rehab services.

COMMENT #4: One comment expressed support for the proposed amendments to the outpatient hospital cardiac and pulmonary rehabilitation rules.

RESPONSE #4: The department thanks the commenter for their support of the rule.

COMMENT #5: One comment expressed support for the department's amendments to the methodology for collecting any upper payment limit overages.

RESPONSE #5: The department thanks the commenter for their support of the rule.

COMMENT #6: One comment expressed that they understand that CMS has instructed the department to make specific calculations related to the measurement of costs related to the upper payment limit; the commenter disagrees with the guidelines set forth by CMS to the department.

RESPONSE #6: The department must follow CMS guidelines set forth regarding the upper payment limit measurement and all calculations related to cost measurement.

COMMENT #7: One comment expressed support of the reimbursement reduction for nonmedically necessary elective deliveries.

RESPONSE #7: The department thanks the commenter for their support of the rule.

COMMENT #8: One comment expressed concern with ICD-10 procedure codes being required on all claims in ARM 37.86.2801(7)(b)(i), and in ARM 37.86.3001(13) as of October 1, 2014.

RESPONSE #8: The ICD-10 wording was proposed prior to the enactment of the Protecting Access to Medicare Act of 2014, delaying the adoption of ICD-10 codes. The department plans to remove ICD-10 reference from the rule and replace it with the following wording: ARM 37.86.2801(7)(b)(i)- Current ICD inpatient procedure codes must be used on all inpatient hospital claims; and ARM 37.86.3001(13) - "ICD-10-CM" means the International Classification of Diseases, Tenth Revision based on the official version of the World Health Organization's Tenth Revision for diagnosis coding, effective for dates of service or discharge date October 1, 2015 and thereafter.

COMMENT #9: One comment expressed concern with the use of ICD-10 procedure codes being required on inpatient and outpatient claims in ARM 37.86.2801(8).

RESPONSE #9: The proposed changes do not state ICD-10 in ARM 37.86.2801(8); the wording states, "current ICD procedure codes."

COMMENT #10: One comment expressed concern with the use of ICD procedure codes on outpatient hospital claims in ARM 37.86.2801(8).

RESPONSE #10: The department will be changing the wording to add CPT codes for outpatient hospital claims. The wording will be changed to state: All hospitals must use current ICD procedure codes for inpatient hospital claims, and current CPT codes for outpatient hospital claims.

COMMENT #11: One commenter expressed concern with the use of condition code 83 in ARM 37.86.2801 for inductions or cesarean sections over 39 weeks. The commenter states that condition code 83 does not allow a facility to report if a cesarean section over 39 weeks was medically necessary.

RESPONSE #11: The department cannot change the wording of condition codes as the definitions come directly from the Uniform Billing Editor Manual and cannot be changed.

COMMENT #12: One commenter expressed support that elective deliveries prior to 39 weeks gestation are not appropriate.

RESPONSE #12: The department thanks the commenter for their support.

COMMENT #13: One commenter expressed concern over ARM 37.86.2801 and states that the department is denying elective cesarean sections. The commenter also states that they feel elective cesareans provide benefits and should be a decision made by the patient. The commenter also states physicians can tell patients that the department does not allow elective cesarean section delivery.

RESPONSE #13: The department does not state that elective cesarean sections are not allowed or will be denied payment; ARM 37.86.2801 states that nonmedically necessary cesarean sections will receive a 33% reduction in reimbursement.

COMMENT #14: One commenter stated that ACOG states full term, greater than 39 and 0/7 days gestation, elective inductions of labor are a viable option.

RESPONSE #14: The proposed changes affect only those inductions prior to 39 weeks gestation.

COMMENT #15: One commenter expressed concern for those members who seek hospital delivery services in an emergency situation, and stated that not all deliveries can be scheduled in advance.

RESPONSE #15: The proposed changes are intended for elective inductions and cesarean sections. An emergency situation is not an elective procedure.

COMMENT #16: Two commenters expressed concern with the changes to ARM 37.86.2902 requiring hospitals to have a policy for all births. The commenters felt requiring policies for non-Medicaid members was outside the scope of Medicaid.

RESPONSE #16: The department intends these proposed changes to apply only to Medicaid and are not intended to apply to non-Medicaid services.

COMMENT #17: One comment was concerned with the use of only the American College of Obstetrics and Gynecologists (ACOG) guidelines for determining gestational age, and that at times care is not begun until after 20 weeks gestation.

RESPONSE #17: The department has added an additional guideline to ARM 37.86.2902(9)(c); if pregnancy care was not initiated prior to 20 weeks gestation, the gestational age may be documented from the first day of the last menstrual period (LMP).

COMMENT #18: Three commenters expressed concern with the elective delivery changes and the distance that some women travel for pregnancy care in Montana.

RESPONSE #18: The department is following ACOG and Joint Commission guidelines on determining medical necessity, and distance from the chosen birthing center is not an ACOG or Joint Commission approved diagnosis for early induction.

COMMENT #19: Three commenters questioned the appeals process for claims that receive a reduced reimbursement for elective deliveries.

RESPONSE #19: The appeals process for these claims is the same as for any claim for medical necessity that Montana Medicaid currently processes.

COMMENT #20: Two commenters expressed concern over using the ACOG guidelines for determining weeks of gestation, and expressed that two of the three guidelines are not used in practice.

RESPONSE #20: The changes to ARM 37.86.2902 state that only one of the criteria must be met to confirm gestational age; the hospital can choose which of the criteria they want to meet.

A large number of comments received were not applicable to the rules being amended in this notice; therefore, they are not being responded to in this notice.

5. These rule amendments are effective July 1, 2014.

/s/ John C. Koch /s/ Richard H. Opper

John C. Koch Richard H. Opper, Director

Rule Reviewer Public Health and Human Services

Certified to the Secretary of State June 16, 2014