Section 148.180  Payment for Pre-operative Days, Patient Specific Orders, and Services Which Can Be Performed in an Outpatient Setting

a)         Pre-operative Days.  For hospitals and distinct part units reimbursed on a per diem basis under Sections 148.160, 148.170 or 148.250 through 148.300, payment for pre-operative days shall be limited to the day immediately preceding surgery unless the attending physician has documented the medical necessity of an additional day or days.  The documentation must be kept in the patient's medical record and must consist of a written notation made by the physician which documents that more than one pre-operative day is medically necessary.

b)         Inpatient Procedures Requiring Justification

1)         A list of restricted inpatient procedures has been established.  These restricted inpatient procedures will only be reimbursed when performed outside the inpatient setting or when the hospital supplies justification for an inpatient admission that meets Departmental established criteria.  These criteria include, but are not limited to:

A)        Presence of medical conditions which make prolonged post-operative observations by a nurse or skilled medical personnel a necessity (e.g., heart disease, severe diabetes);

B)        The patient is in the hospital as an inpatient for a medically necessary condition unrelated to the surgical procedure;

C)        An unrelated procedure is being done simultaneously which itself requires surgical hospitalization;

D)        The practitioner has documented the medical necessity of performing the patient's surgery in an inpatient setting;

E)         The patient is unable to comprehend and/or follow the necessary instruction both prior to and following the procedure due to mental and/or physical impairment, and this would result in inadequate treatment and place the patient at risk;

F)         Emergency admission or recent onset of severe symptoms would prohibit safely performing the procedure on an outpatient basis (e.g., bleeding, severe pain, nausea, vomiting); and

G)        Admission occurs subsequent to the performance of the procedure on an outpatient basis due to conditions such as:

i)          Instability of vital signs;

ii)         Respiratory distress greater than existed pre-operatively;

iii)         Post-operative pain not relieved by oral medication;

iv)        Uncontrollable bleeding;

v)                  Lack of state of consciousness appropriate to age and development;

vi)                 Presence of persistent nausea or vomiting; and

vii)        Inability to ambulate consistent with age, previous mobility status and/or procedure.

2)         The list of procedures identified as restricted inpatient procedures which may be safely performed outside the inpatient setting and do not require an inpatient admission are reevaluated periodically.

3)         Additions to and deletions from the list of designated restricted inpatient procedures will be made following notice to and consultations with the Department's professional advisory committees, State Medicaid Advisory Committee, representatives selected by the hospitals, other third party payors, the Illinois Hospital Association, and other interested groups or individuals.

c)         Ancillary Services and Tests

1)         Ancillary services and routine tests (those services other than routine room and board and nursing which are required because of the patient's medical condition, including lab tests and x-rays) shall not be covered unless there is a patient specific written order for the test from the attending or operating physician responsible for the care and treatment of the patient.  The attending or operating physician responsible for the care and treatment of the patient is required to sign all applicable sections for each test ordered in the appropriate place in the medical record.  The order must be legible and explain completely all services or tests to be performed. Standing orders are not acceptable.

2)         Upon completion of the service or test, a fully documented description of results with findings, or the administration of medication, must be maintained in the patient medical records.  Radiological services must have the actual x-rays and the interpretation report; laboratory/pathological tests must have the specific findings for each test; and drugs and pharmaceutical supplies must indicate strength, dosages and durations.

3)         Charges for any and all such services or tests cannot exceed those charged to the general public.  The failure to maintain and provide records as described in this Section shall result in the disallowance of the applicable charges upon audit.

(Source:  Amended at 18 Ill. Reg. 3450, effective February 28, 1994)