Section 1163.52. Prospective payment methodology

(a) The Department will base payment for inpatient hospital services on the classification of inpatient hospital discharges by DRGs used by the Medicare Program.

(b) The Department will assign a DRG to each MA discharge. The assignment of a DRG is based on:

(1) The recipient’s diagnoses.

(2) The procedures performed during the recipient’s hospital stay.

(3) The recipient’s sex.

(4) The recipient’s age.

(5) The recipient’s discharge status.

(c) For a DRG, the Department will determine a relative value which reflects the cost of hospital resources used to treat cases in that DRG relative to the Statewide average cost of hospital cases. The Department will determine the relative value under § 1163.122 (relating to determination of DRG relative values).

(d) The Department will base payment for compensable inpatient hospital services under the DRG payment system on the hospital’s base DRG rate determined under § 1163.126 (relating to computation of hospital specific base payment rates).

(e) The Department will not make a separate APR-DRG payment for a normal newborn when the following occur:

(1) The hospital receives an APR-DRG payment for the mother’s obstetrical delivery.

(2) The newborn meets the definition of a ‘‘normal newborn’’ under § 1163.2 (relating to definitions).

(3) The normal newborn is discharged from the hospital before or on the same date as the mother.

(4) The normal newborn is not discharged to another inpatient setting.

The provisions of this § 1163.52 adopted September 23, 1983, effective September 24, 1983, 13 Pa.B. 2881; amended June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended October 10, 1986, effective retroactively to July 1, 1986, 16 Pa.B. 3828; amended November 7, 1986, effective July 1, 1986, 16 Pa.B. 4384; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241; amended April 13, 2012, effective for dates of discharge on and after May 1, 2012, 42 Pa.B. 2023. Immediately preceding text appears at serial page (337503).

Notation

Authority

The provisions of this § 1163.52 amended under sections 201, 403(b), 403.1 and 443.1(1) of the Public Welfare Code (62 P. S. § § 201, 403(b), 403.1 and 443.1(1)).