471 NAC 10-002. DEFINITIONS

002. DEFINITIONS. The following definitions apply: 002.01 ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance costs. 002.02 ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR DRG). The All-Patient Refined Diagnosis-Related Group (APR DRG) software application that assigns patients into categories based on severity of illness and risk of mortality. 002.03 AMBULATORY ROOM AND BOARD. Accommodations for families and beneficiaries undergoing acute, long-term inpatient or outpatient hospital treatment. To qualify for this service, the location of the hospital where the beneficiary is receiving care must be 90 miles or greater from the beneficiary’s or family’s home. 002.04 ANCILLARY SERVICES. Ancillary services are supportive or diagnostic measures that supplement and support a primary physician, nurse, or other healthcare provider in treating a patient. 002.05 BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates. 002.06 CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year. 002.07 CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average. 002.08 Clinical Trials. For services not subject to Food and Drug Administration (FDA) approval, clinical trials fall into one of three phases. 002.08(A) PHASE I CLINICAL TRIALS. Initial introduction of an investigational service into humans. 002.08(B) PHASE II CLINICAL TRIALS. Controlled clinical studies conducted to evaluate the effectiveness of the service for a particular indication or medical condition of the patient; these studies are also designed to determine the short-term side effects and risks associated with the new service. 002.08(C) PHASE III CLINICAL TRIALS. Clinical studies to further evaluate the effectiveness and safety of a service that is needed to evaluate the overall risk or benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the new service to the current recommended standard of care. 002.09 COMORBIDITY. The simultaneous presence of two chronic diseases, or conditions, in a patient. 002.10 COORDINATION PLAN. An overall program outline for the delivery of a specific service; it is not an individual patient care plan. 002.11 COST OUTLIER. Cases which have an extraordinarily high cost as established in this title as eligible for additional payments above and beyond the initial diagnosis-related group (DRG) payment. 002.12 CRITICAL ACCESS HOSPITAL (CAH). A hospital licensed as a critical access hospital (CAH) by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a critical access hospital (CAH). 002.13 DIAGNOSIS-RELATED GROUP (DRG). A group of similar diagnoses combined based on patient age, birth weight, procedure coding, comorbidity, and complications. 002.14 DIAGNOSIS-RELATED GROUP (DRG) WEIGHT. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis-related group (DRG) and severity of illness . 002.15 DIAGNOSTIC SERVICE. An examination or procedure performed either on the patient, or materials obtained from the patient, to provide information for the diagnosis or treatment of a disease or to assess a medical condition. This may include radiological and pathological services. 002.16 DIALYSIS. A process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. 002.17 DIRECT MEDICAL EDUCATION (DME) COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education (DME) costs associated with approved intern and resident programs. 002.18 DISTINCT PART UNIT. A Medicare-certified hospital-based substance use disorder, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare. 002.19 DURABLE MEDICAL EQUIPMENT. Equipment which withstands repeated use is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the beneficiary’s home. 002.20 EMERGENCY MEDICAL CONDITION. A medical or behavioral condition, the onset of which is sudden, manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could result in: (A) Placing the health of the beneficiary or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy; (B) Serious impairment to such person's bodily functions; (C) Serious dysfunction of any bodily organ or part; or (D) With respect to a pregnant woman who is having contractions: (i) Inadequate time to effect a safe transfer to another hospital before delivery; or (ii) That transfer may pose a threat to the health or safety of the woman or the unborn child. 002.21 EXTENDED STAY. An inpatient hospital stay during which a beneficiary no longer requires acute in-patient care, and more than five days for discharge planning have passed. 002.22 HEALTH CARE-ACQUIRED CONDITIONS (HAC). A health care-acquired condition (HAC) means a condition occurring in any inpatient hospital setting, identified as a hospital-acquired condition (HAC) by Medicare that is reasonably preventable and was not present or identifiable at hospital admission but is either present at discharge or documented after admission . 002.23 HOSPITAL EMERGENCY SERVICES. Services that are necessary to prevent the death of the beneficiary or serious impairment of the beneficiary’s health and, because of the threat to the life or health of the beneficiary , necessitate the use of the most accessible hospital equipped to provide the necessary services. 002.24 HOSPITAL INPATIENT SERVICES. Services that: (A) Are ordinarily furnished in a hospital for the care and treatment of inpatients; (B) Are furnished under the direction of a physician or dentist; (C) Are furnished in an institution that: (i) Is maintained primarily for the care and treatment of patients with disorders other than mental diseases; (ii) Is licensed or formally approved as a hospital by an officially designated authority for state standard-setting; (iii) Is enrolled with and certified by Medicare for participation as a hospital; and (iv) Has in effect a utilization review (UR) plan, applicable to all Nebraska Medicaid beneficiaries, that meets the requirements of federal regulations , unless a waiver has been granted by the Secretary of the United States Department of Health and Human Services; and (D) Do not include special needs facilities and independent clinical laboratory services furnished by a hospital with a swing-bed approval. 002.25 HOSPITAL MERGERS. Hospitals that have combined into a single entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Nebraska Medicaid provider number. 002.26 HOSPITAL OUTPATIENT OBSERVATION SERVICES. Outpatient observation services are those services furnished by a hospital on the hospital premises, including use of a bed and periodic monitoring by a hospital’s nursing staff or other staff, which are reasonable and necessary to determine the need for a possible admission to the hospital as an inpatient. Some beneficiaries may require a second day of outpatient observation services. A maximum of 48 hours of outpatient observation may be reimbursed. When a beneficiary receives hospital outpatient observation services and is thereafter admitted as an inpatient of the same hospital, the hospital observation services are included in the hospital's payment for the inpatient services. 002.27 HOSPITAL OUTPATIENT SERVICES. Preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients under the direction of a physician, optometrist, ophthalmologist, audiologist, or dentist in an institution that meets provider requirements. 002.28 HOSPITAL-AFFILIATED AMBULATORY SURGICAL CENTER (HAASC). An ambulatory surgical center (ASC) operated by a hospital. A hospital-affiliated ambulatory surgical center (HAASC) may be covered under Medicare, and therefore under Nebraska Medicaid, as an ambulatory surgical center (ASC) or a hospital-affiliated ambulatory surgical center (HAASC). 002.29 HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital-specific operating allowable cost associated with treating Nebraska Medicaid beneficiaries. Operating costs include the major moveable equipment portion of capital-related costs but exclude the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical education costs. 002.30 HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO (CCR). Hospital-specific cost-to-charge ratio (CCR) is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios (CCR) used for outlier cost payments and transplant diagnosis-related group (DRG) cost-to-charge ratio (CCR) payments are derived from the outlier cost-to-charge ratios (CCR) in the Medicare inpatient prospective payment system. 002.31 INDEPENDENT CLINICAL LABORATORY . A laboratory which is operated by or under the supervision of a hospital or the organized medical staff of the hospital which does not meet the definition of a hospital is considered to be an independent laboratory. However, a laboratory serving hospital inpatients and outpatients and operated on the premises of a hospital which meets the definition of a hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not classified as an independent clinical laboratory. The hospital's certification covers the services performed in this laboratory. 002.32 INDIRECT MEDICAL EDUCATION (IME) COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education cost payments. 002.33 INFANT OR INFANCY. The time period from an individual’s birth through completion of one year of age. 002.34 INPATIENT. A beneficiary who has been admitted to a medical institution as an inpatient on the recommendation of a physician or dentist and who: (A) Receives room, board, and professional services in the institution for a 24-hour period or longer; or (B) Is expected by the institution to receive room, board, and professional services in the institution for a 24-hour period or longer even though it later develops that the beneficiary dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours. 002.35 INPATIENT DAYS. The number of days of care covered for inpatient hospital services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Nebraska Medicaid reporting purposes, even if the hospital uses a different definition of a day for statistical or other purposes. The day of admission is counted as a full day. 002.35(A) PART OF DAY. Except for the day of admission, a part of a day, including the day of discharge, death, or a day on which a beneficiary begins a leave of absence, is not counted as a day. Charges for ancillary services on the day of discharge or death, or the day on which a beneficiary begins a leave of absence are covered. If inpatient admission and discharge or death occur on the same day, the day is considered a day of admission and counted as one inpatient day. 002.35(B) ANCILLARY AREAS. When a registered inpatient is occupying any other ancillary area, such as surgery or radiology, at the census-taking hour before occupying an inpatient bed, the beneficiary must be included in the inpatient census of the routine care area, not the ancillary area. 002.35(C) MEDICARE METHODOLOGY. The methodology that Medicare requires to be used to account for inpatient accommodations on the Medicare cost report. 002.36 LONG-TERM ACUTE CARE HOSPITAL (LTACH). A hospital that is licensed as a general acute care hospital that focuses on treating patients requiring extended hospital-level care, typically following initial treatment at a general acute care hospital. Patients treated in a long-term acute care hospital (LTACH) are not generally appropriate for lower level of care (LOC) settings but are expected to improve to lower level of care (LOC) status. 002.37 NEBRASKA MEDICAID ALLOWABLE INPATIENT CHARGES. Nebraska Medicaid allowable inpatient charges equal the total claim submitted charges less the non-allowable amount. 002.38 NEBRASKA MEDICAID ALLOWABLE INPATIENT DAYS. Nebraska Medicaid allowable inpatient days are the total number of covered Nebraska Medicaid inpatient days. 002.39 NEBRASKA MEDICAID RATE PERIOD. The period of July 1 through the following June 30. 002.40 MEDICAL NECESSITY. Health care services and supplies which are medically appropriate and: (A) Necessary to meet the basic health needs of the beneficiary ; (B) Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service; (C) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies; (D) Consistent with the diagnosis of the condition; (E) Required for means other than convenience of the beneficiary or his or her physician; (F) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; (G) Of demonstrated value; and (H) No more intense level of service than can be safely provided. 002.41 MEDICAL REVIEW. Review of Nebraska Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay; completeness; adequacy; quality of care; appropriateness of admission; discharge and transfer; and appropriateness of prospective payment outlier cases. 002.42 MEDICAL SOCIAL SERVICES. Medical social services are those social services which contribute meaningfully to the treatment of a beneficiary’s condition. 002.43 MEDICAL SUPPLIES. Expendable or specified reusable supplies required for care of a medical condition and used in the beneficiary’s home must be prescribed by a physician or other licensed practitioner within the scope of their licensure. This includes dressings, colostomy supplies, catheters, and other similar items. 002.44 MEDICARE COST REPORT. The report filed by each facility with its Medicare intermediary. A hospital that does not participate in the Medicare program will complete the Medicare cost report in compliance with Medicare principles and supporting rules, regulations, and statutes. The hospital will file the completed form with Nebraska Medicaid within five months after the end of the hospital's reporting period. A 30-day extension of the filing period may be granted if requested in writing before the end of the five-month period. Completed Medicare cost reports are subject to audit by Nebraska Medicaid or its designees. If a nursing facility is affiliated with the hospital, the nursing facility cost report must be filed as outlined in these regulations. 002.45 NEONATAL INTENSIVE CARE. Intensive care services provided to an infant in an intensive care unit specially equipped to care for infants. 002.46 NEW OPERATIONAL FACILITY. A new operational facility is created neither by virtue of a change in ownership nor by the construction of additional beds to an existing facility. A new operating facility provides inpatient hospital care that meets one of the following criteria: (A) A licensed newly constructed facility, which either totally replaces an existing facility, or which is built at a site where hospital inpatient services have not previously been provided; (B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or (C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months. 002.47 NON-PATIENT. A beneficiary receiving services who is neither an inpatient nor an outpatient. When a sample or specimen is obtained by personnel not employed by the hospital and is sent to the hospital for tests, the tests are non-patient services because the beneficiary is not registered as an inpatient or an outpatient of the hospital. If the sample is obtained by hospital personnel, the tests are outpatient services. 002.48 NURSERY CARE. Services for a newborn child from time of birth to time of discharge of the mother from the facility. 002.49 OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education (DME) costs, and graduate medical education costs. 002.50 OTHER PROVIDER-PREVENTABLE CONDITIONS (OPPC). A 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. 002.51 ORTHOTICS. Rigid or semi-rigid devices to prevent or correct physical deformity or malfunction, to support a weak or deformed part of the body, or to eliminate motion in a diseased or injured part of the body. 002.52 OUTPATIENT. A person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services. 002.53 PASS OR LEAVE OF ABSENCE. A patient is absent from the hospital but has not been discharged from the facility. A hospital may place a patient on a leave of absence when readmission is expected, and the patient does not require a hospital level of care during the interim period. 002.54 PATHOLOGICAL SERVICES. Microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or other pathological examinations or procedures performed on materials obtained from the patient to provide information for the diagnosis or treatment of a disease or an assessment of the medical condition of the patient. 002.55 Present on Admission (POA) Indicator. A status code the hospital uses on an inpatient claim that indicates if a condition was present or incubating at the time the order for inpatient admission occurs. 002.56 Prosthetic. A device which replaces a missing part of the body. 002.57 Provider-Preventable Conditions (PPC). An umbrella term which is defined as two distinct categories: health care-acquired conditions (HCAC) and other provider-preventable conditions (OPPC). 002.58 Radiological Services. Services in which x-rays or rays from radioactive substances are used for diagnostic or therapeutic purposes and associated medical services necessary for the diagnosis and treatment of the patient. 002.59 Reporting Period. Same reporting period as that used for its Medicare cost report. 002.60 Resource Intensity. The relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular disease. 002.61 Risk of Mortality (ROM). The likelihood of dying. 002.62 RURAL EMERGENCY HOSPITAL. A hospital licensed as a rural emergency hospital by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a rural emergency hospital. A rural emergency hospital solely provides outpatient services, including emergency department services, observation care, and additional outpatient medical and health services that do not exceed an annual per patient length of stay of 24 hours on average. 002.63 Severe Obesity. Body Mass Index greater than 35. 002.64 Severity of Illness Level . The extent of physiologic decompensation or organ system loss of function. 002.65 SWING BED. Post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment observation, and assessment. 002.66 SWING BED FACILITY. A rural acute hospital which is certified to provide skilled nursing facility (SNF) level of care. 002.67 Tax-Related Costs. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to federal public laws or any amendments thereto, franchise fee, license fee, or hospital specific tax, fee or assessment imposed by the local, state, or federal government, but not including income taxes. 002.68 Therapeutic Services. Services and supplies which are not diagnostic services, are furnished incident to the services of physicians and practitioners, and which aid physicians and practitioners in the treatment of patients. 002.69 TRANSPLANT DIAGNOSIS-RELATED GROUPS (DRG). Transplant diagnosis- related groups (DRG) are identified in the All-Patient Refined Diagnosis-Related Group (APR DRG). Nebraska Medicaid does not recognize bone marrow transplant diagnosis-related groups in its classification with all other transplant diagnosis-related groups categorized by the All-Patient Refined Diagnosis-Related Group (APR DRG). Bone marrow transplant diagnosis-related groups do not receive a transplant cost-to-charge ratio or transplant direct medical education (DME) payment. The bone marrow transplant diagnosis-related groups per discharge payment is the sum of the operating cost payment amount, the capital-related cost payment, and when applicable a direct medical education (DME) cost payment, indirect medical education (IME) cost payment, and a cost outlier payment. 002.70 Uncompensated Care. Uncompensated care includes the difference between costs incurred and payments received in providing services to Nebraska Medicaid beneficiary and uninsured. 002.71 Ward. Either: (A) A large room in the hospital for the accommodation of several patients; or (B) A division within a hospital for the care of numerous patients having the same condition.