Chapter 3701-14 DRG Reporting Requirements

3701-14-01 Definitions and DRG reporting requirements.

(A) As used in this rule:

(1) "ADRG" means the adjacent diagnosis-related groups as defined by the DRG refinement system.

(2) "DRG" or "DRGs" means the diagnosis-related group or groups that a hospital assigns based upon the clinical record of the patient for the purpose of classifying inpatient hospital services and determining reimbursement for services performed.

(3) "Charge outlier case" means a patient discharged from the hospital whose total charges are equal to or greater than the charge trim point for that patient's DRG.

(4) "Charge trim point" means two standard deviations above the arithmetic mean of charges for all cases in a DRG.

(5) "Day outlier case" means a patient discharged from the hospital whose total number of inpatient days are equal to or greater than the length of stay trim point for that patient's DRG.

(6) "DRG refinement system" means the severity of illness classification system developed by the "Health Systems Management Group, School of Management, Yale University," as updated by the director of health.

(7) "HSMG refinement grouper" means of the software which implements the DRG refinement system, as updated by the director of health for discharges on or after October first of each year.

(8) "Hospital" means an institution classified and registered as a hospital under section 3701.07 of the Revised Code.

(9) "ICD-9-CM procedure code" means an identifier assigned to describe the medical procedure used for the treatment of illness and injury.

(10) "Length of stay trim point" means two standard deviations above the arithmetic mean of the length of stay for all cases in a DRG.

(11) "LOS" or "length of stay" means the number of days a patient is in the hospital per admission as calculated by counting the number of days from and including the day of admission up to but not including the day of discharge.

(12) "Mean" means the arithmetic average that is calculated by adding the values and dividing by the number of cases.

(13) "Median" means the middle case where fifty per cent of the cases have lower values and fifty per cent of the cases have higher values.

(14) "Outpatient procedure" means a non-urgent medical procedure performed on an outpatient basis in a hospital under the supervision of a physician for the diagnosis or treatment of a disease or other disorder. "Outpatient procedure" does not include procedures performed in clinics or other settings where only ancillary services are provided or where physician services are not typically provided, such as radiology, laboratory services, physical rehabilitation, renal dialysis, or pharmacy.

(15) "Range" means the lowest and the highest values.

(16) "Refinement class" means the severity level within each ADRG, as defined by the DRG refinement system and HSMG refinement grouper, in which a patient may be classified based on the extent that a patient's illness involves multiple complications and comorbid conditions requiring a certain degree of complexity in treatment and diagnosis.

(17) "Refinement group number" or "RGN" means the complete four-digit number assigned by the HSMG refinement grouper which consists of the ADRG code number in character positions one through three and the refinement class code number in character position four.

(18) "Trim points" mean charge trim point and length of stay trim point.

(19) "Primary procedure code" means the code that identifies the principal procedure performed during the period covered by a bill and the date on which the principal procedure described on the bill was performed.

(B) On or before the first day of May each year, every hospital shall disclose to the director of health the following inpatient data:

(1) The total number of patients in each of the sixty DRGs most frequently treated on an inpatient basis in the hospital as represented by discharges during the previous calendar year and based upon the DRG grouper in effect on the first day of October of the calendar year preceding the calendar year which the patient was discharged. If DRG 468, 469, or 470 appears on the list of most frequently treated DRGs, the DRG or DRGs shall be removed from the list and the next most frequently treated DRG or DRGs shall be substituted in its place:

(a) The total number of patients discharged;

(b) The mean, median, and range of total hospital charges;

(c) The mean, median, and range of length of stay;

(d) The number of admissions from each of the following:

(i) Emergency room: For the purposes of this provision, "admissions from emergency room" means the number of patients admitted to the hospital through the emergency room upon the recommendation of a physician;

(ii) Transfer from another hospital;

(iii) Other sources of admission including, but not limited to, skilled nursing facilities or health care facilities other than an acute care hospital; referrals from a personal physician, clinic physician, health maintenance organization, a court of law; a newborn if the patient was born in the facility; and those admissions for which information is not available;

(e) The number of cases, mean charges, and mean length of stay in each refinement class or refinement group number excluding all charge outlier cases and day outlier cases based on the trim points provided and published by the director at least one hundred twenty days prior to May first each year; and

(2) The number of patients falling within DRG numbers 468, 469, and 470.

Paragraphs (B)(1)(a) to (B)(1)(d) of this rule do not require the disclosure of data for any DRG for which the hospital treated fewer than ten patients during the year. Paragraph (B)(1)(e) of this rule does not require the disclosure of data for any refinement group number for which the hospital treated less than three patients during the year.

(C) On or before the first day of May each year, every hospital shall disclose to the director of health the following outpatient data:

(1) The total number of patients in each of the sixty most frequently performed outpatient primary procedures in the hospital as reported by ICD-9-CM primary procedure codes for patients treated during the previous calendar year.

(2) The mean and median of the total hospital charges for those sixty most frequently performed outpatient procedures identified in paragraph (C)(1) of this rule.

(3) The hospital is not required to disclose data for any procedure for which the hospital treated fewer than ten patients during the year.

(D) Each hospital shall:

(1) Submit the hospital identification and certification form, prescribed in appendix A of this rule, signed by the chief executive officer of the hospital;

(2) Submit the inpatient data required to be reported under this rule to the director in an electronic format as provided in appendix B of this rule, or in a paper format as provided in appendix C to this rule, and report the DRG data required by paragraph (B)(1) of this rule in descending order according to the frequency of admissions with the DRG having the most frequent number of admissions reported first;

(3) Submit the outpatient data required to be reported under this rule to the director in an electronic format as provided in appendix D to this rule and report the procedure data required by paragraph (C) of this rule in descending order according to the frequency of patients with the procedure having the most frequent number of patients reported first.

(E) Each hospital may include with the data disclosed under this rule commentary concerning reasons for major deviations in the range of data for any DRG. The hospital shall submit the commentary in the format prescribed by appendix C to this rule. Any release of the data disclosed under this rule identifying a hospital shall include the commentary, if any, submitted by the hospital pursuant to this paragraph.

(F) Any releases by the department of information collected pursuant to section 3727.34 of the Revised Code that list charge data by hospital shall include conspicuous language explaining that the data in the report either has been reported by severity of illness or adjusted with respect to the severity of illness of the patients and that an individual hospital's average charges may differ significantly from the average charges of a group of hospitals because of a variety of reasons including, but not limited to:

(1) Indigent care and bad debt loads;

(2) Medical education costs;

(3) Physician practice patterns;

(4) Capital requirements;

(5) Hospital location;

(6) Local labor market conditions; and

(7) Other operating requirements.

(G) Under no circumstances shall the name or social security number of a patient, dentist or physician be submitted under this rule.

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Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33, 3727.36, 3727.40, 3727.41
Prior Effective Dates: 12/28/1987, 9/5/89, 1/27/07

3701-14-02 Definitions.

As used in rules 3701-14-02 to 3701-14-04 of the Administrative Code:

(A) "ACEI" or "angiotensin-converting enzyme inhibitor" means a medicine used for controlling blood pressure, treating heart failure, preventing strokes, and preventing kidney damage in people with hypertension or diabetes and improving survival after heart attacks.

(B) "AHRQ" means the agency for healthcare research and quality, a public health service agency in the United States department of health and human services.

(C) "AMI" or "acute myocardial infarction" means a heart attack that occurs when the blood supply to part of the heart is interrupted.

(D) "ARB" or "angiotensin receptor blocker" means a drug that helps relax blood vessels and is used for controlling high blood pressure, treating heart failure, and preventing kidney failure in people with diabetes or high blood pressure.

(E) "Bacteremia" means bacteria present in the blood stream, as confirmed by culture.

(F) "C. diff" or "Clostridium difficile" means a bacterium that produces a toxin that causes an intestinal condition called colitis, sometimes with severe complications.

(G) "CABG" or "coronary artery bypass graft" means a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease.

(H) "CDC" means the centers for disease control and prevention within the United States department of health and human services.

(I) "Children's hospital" has the same meaning as in division (B)(1) of section 3727.01 of the Revised Code.

(J) "CMS" means the centers for medicare and medicaid services within the United States department of health and human services.

(K) "CWISH" means the council of women and infants' specialty hospitals which is a national membership organization of non-profit hospitals providing services to women and infants.

(L) "Department" means the department of health of the state of Ohio.

(M) "Director" means the director of the department of health of the state of Ohio or his or her duly authorized representative.

(N) "DSC" means the joint commission's disease specific care measure.

(O) "First calendar quarter" means the time period that includes the months of January, February, and March.

(P) "First quarter" means the first, second and third months of any twelve month period.

(Q) "Fourth calendar quarter" means the time period that includes the months of October, November, and December.

(R) "Fourth quarter" means the tenth, eleventh, and twelfth month of any twelve month period.

(S) "HCAHPS" or "hospital consumer assessment of healthcare providers and systems" means the survey developed by CMS to collect information on hospital patients' perspectives of the care they received while in the hospital.

(T) "HF" or "heart failure" means a cardiac condition that occurs when a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs.

(U) "Hospital" means an institution as defined in section 3727.01 of the Revised Code.

(V) "ICU" means intensive care unit.

(W) "IQI" or "inpatient quality indicator" means a measure developed by AFIRQ to reflect quality of care in hospitals.

(X) "LVSD" or "left ventricular systolic dysfunction" means a common cause of heart failure due to a malfunctioning left ventricle of the heart.

(Y) "MRSA" or "methicillin resistant staphylococcus aureus" means a type of bacterium that can cause infections in humans that can not be successfully treated with semisynthetic penicillins.

(Z) "MSSA" or "methicillin susceptible staphylococcus aureus" means a type of bacterium that can cause infections in humans that can be successfully treated with semisynthetic penicillins.

(AA) "NPIC" means the national perinatal information center, a non-profit organization with a charter membership of major perinatal centers across the United States.

(BB) "NQF" means the national quality forum, a not-for-profit membership organization that endorses national consensus standards for measuring and public reporting on performance of health care providers.

(CC) "PCTA" or "percutaneous transluminal coronary angioplasty" means a medical procedure used to restore blood flow through a narrowed or blocked artery in the heart.

(DD) "PN" or "pneumonia" means a serious infection or inflammatory illness of the lungs which hinders oxygen reaching the lungs.

(EE) "PSI" or "patient safety indicator" means a measure developed by AHRQ to reflect potential inpatient complications and other patient safety concerns following surgeries, other procedures, and childbirth.

(FF) "Quarter" means a time period of three consecutive months.

(GG) "SCIP" or "surgical care improvement project" means a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications.

(HH) "Second calendar quarter" means the time period that includes the months of April, May, and June.

(II) "Second quarter" means the fourth, fifth, and sixth months of any twelve month period.

(JJ) "The Joint Commission" means the independent, not-for-profit organization formerly known as the joint commission on accreditation of healthcare organizations or the joint commission on accreditation of hospitals that accredits and certifies health care organizations and programs in the United States.

(KK) "Third calendar quarter" means the time period that includes the months of July, August, and September.

(LL) "Third quarter" means the seventh, eighth, and ninth months of any twelve month period.

(MM) "Twelve month reporting period" means a length of time comprised of twelve consecutive months.

Effective: 1/25/2015
Five Year Review (FYR) Dates: 11/10/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3 727.41
Rule Amplifies: 3727.33
Prior Effective Dates: 6/28/2009

3701-14-03 Hospital performance measures reporting requirements.

(A) Except as otherwise provided in this rule, commencing with the first reporting deadline that occurs at least ninety days after the effective date of this rule, each hospital shall submit information to the director, in accordance with the provisions of rules 3701-14-02 to 3701-14-04 of the Administrative Code, showing the hospital's performance in meeting each of the measures specified in appendix A to rule 3701-14-04 of the Administrative Code.

(1) Not later than the first day of each April, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the twelve month reporting period ending on June thirtieth of the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of this reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth quarters of this reporting period. The third and fourth quarters of this reporting period are the first and second calendar quarters of the previous calendar year.

(2) Not later than the first day of each October, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of the reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth calendar quarters of the previous calendar year.

(3) If the first reporting deadline that occurs at least ninety days after the effective date of this rule is October 1, 2009, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures specified in rule 3701-14-04 of the Administrative Code for all of calendar year 2008.

(4) Children's hospitals are exempted from reporting a performance, quality or service measure for patients eighteen years of age or older.

(5) Hospitals that are not currently participating in the hospital consumer assessment of healthcare providers and systems shall commence reporting the HCAHPS measures beginning October 2011.

(6) Hospitals that are not stroke centers certified by the joint commission shall commence reporting the stroke measures beginning October 2012.

(B) In addition to the measures required to be reported in paragraph (A) of this rule:

(1) Beginning October 2010, each hospital shall report annually each October, the health care provider influenza vaccination information in appendix B to rule 3701-14-04 of the Administrative Code for the flu season beginning on September first of the previous calendar year and ending on March thirty-first of the reporting year; and

(2) Beginning October 2011, each hospital shall submit, in accordance with paragraph (A) of this rule, information reflecting the hospital's performance in meeting the perinatal and pediatric measures specified in appendix E to rule 3701-14-04 of the Administrative Code.

(C) The hand-washing program and infection control staff information shall be reported and updated once each reporting time period in April and October reflecting the information as of the end of the fourth quarter of the reporting period.

(D) The AMI thirty-day mortality measure shall be reported once annually each October reflecting the twelve month reporting period ending on June thirtieth of the previous calendar year.

(E) The following perinatal measures shall be calculated by the department from the birth records submitted by each hospital pursuant to section 3705.02 of the Revised Code:

(1) Infants under fifteen hundred grams not delivered at the appropriate level of care;

(2) Appropriate use of antenatal steroids; and

(3) Caesarean rate for low-risk first birth women.

(F) In submitting the information, each hospital shall do all of the following:

(1) Submit information for each measure electronically, in a manner prescribed by the director, through the department's website created for this purpose:

(a) If a hospital does not provide the service that is the subject of a performance, quality, or service measure, the hospital shall not enter any data for that measure.

(b) If a hospital commences operation or starts serving a new population in the middle of a calendar quarter, the hospital shall not enter any data for the partial quarter, but shall submit the performance measure information starting with the first full quarter of hospital operation or serving the new population.

(2) Submit the following identifying information:

(a) The hospital's name, address, hospital registration number issued pursuant to section 3701.07 of the Revised Code, medicare provider number, if applicable, and the hospital's main telephone number; and

(b) The name of the person submitting the information and a telephone number and e-mail address for that person.

(3) Submit the information for the hospital's services regardless of who pays the charges incurred for the services;

(4) Submit the numerator and denominator for each performance measure that is calculated as a per cent or rate; and

(5) Unless otherwise provided in rules 3701-14-03 and 3701-14-04 of the Administrative Code:

(a) Use the specifications for the measure that the entity that developed or endorsed the measure recommends be used for each quarter in the reporting period for which information is being submitted;

(b) If the specifications permit use of a sampling methodology, indicate if sampling is used to calculate the measure; and

(c) Adjust for risk, as needed, the information for a particular measure in accordance with the risk adjustment methodology that the entity that developed or endorsed the measure recommends be used for each quarter of the reporting period for which information is being submitted.

(G) Under no circumstances shall the name or social security number of a patient, physician, or dentist, or any other health care practitioner, be included in the information submitted under this rule.

(H) A hospital may include comments regarding the measures when submitting the information under rules 3701-14-02 to 3701-14-04 of the Administrative Code. The hospital's commentary shall be included in the display of the hospital's information on the department's internet website.

(I) The director may waive the reporting of a measure if the director determines that the entity that created or endorsed the measure has failed to timely make available updates to the measure, has materially altered the measure in such a way to make reporting or calculation of the measure unreasonably difficult, or has discontinued the measure.

(J) A hospital may verify the accuracy of, and make corrections to, the information submitted to the director or calculated by the department pursuant to rules 3701-14-02 to 3701-14-04 of the Administrative Code anytime prior to the data being made available to the public under paragraph (M) of this rule.

(K) A hospital shall submit amended data for the surgical site infection measures required to be reported if a procedure was performed in a period that has already been reported and an infection related to that procedure is detected subsequent to the initial submission of information:

(1) Within thirty days after the operative procedure if no implant is left in place; or

(2) Within three hundred sixty-five days after the operative procedure if an implant is left in place.

(L) The director may audit any information submitted to the director under section 3727.22 of the Revised Code and rules 3701-14-02 to 3701-14-04 of the Administrative Code, including information adjusted for risk. The director may accept the audit reports from the CMS and the joint commission that are pertinent to their measures, if the director determines the audit reports are representative of the reporting period in question.

(M) Not later than ninety days after a hospital submits information to the director under this rule, the director shall make the submitted information available for sale to any interested person or government entity and available on the department's internet website. The director shall:

(1) Exclude from sale and from the website, and not otherwise make available to the public, information that compromises patient privacy; and

(2) Exclude from the website, a hospital's information for a particular measure if the hospital's caseload is determined by the director to be insufficient to make the information a reliable indicator of the hospital's quality. The director shall consider the specifications manual issued by CMS and the joint commission when making this determination.

(N) If a hospital fails to timely submit the information required by rules 3701-14-02 to 3701-14-04 of the Administrative Code, the director may apply to the court of common pleas of the county in which a hospital is located for a temporary or permanent injunction restraining the hospital from failure to comply with these rules.

Replaces: 3701-14-02

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33, 3727.331, 3727.35, 3727.39, 3727.40, 3727.41
Prior Effective Dates: 1/27/2007, 6/9/09

3701-14-04 Performance measures to be reported.

In accordance with rule 3701-14-03 of the Administrative Code, each hospital that is not a children's hospital shall report to the director all of the following measures, and each children's hospital shall report only the infection control measures and the pediatric measures listed in paragraphs (F) and (G) of this rule.

(A) The CMS and the joint commission's measures for acute myocardial infarction, heart failure, pneumonia, the surgical improvement project, and the hospital consumer assessment of healthcare providers and systems listed in appendix A to this rule.

(1) In calculating the appropriateness of care measure for acute myocardial infarction, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, and AMI-8a interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure, but not counted in the numerator of the AMI appropriateness of care measure.

(b) If an eligible patient receives all indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure and once in the numerator of the AMI appropriateness of care measure.

(2) In calculating the appropriateness of care measure for heart failure, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for HF-1, HF-2, HF-3 and HF-4 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure, but not counted in the numerator of the HF appropriateness of care measure.

(b) If an eligible patient receives all indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure and once in the numerator of the HF appropriateness of care measure.

(3) In calculating the appropriateness of care measure for pneumonia, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for PN-2, PN-3, PN-4, PN-5c, PN-6 and PN-7 who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure, but not counted in the numerator of the PN appropriateness of care measure.

(b) If an eligible patient receives all indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure and once in the numerator of the PN appropriateness of care measure.

(4) In calculating the appropriateness of care measure for the surgical care improvement project infection measures, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for SCIP-Inf-1, SCIP-Inf-2, and SCIP-Inf-3 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure, but not counted in the numerator of the SCIP appropriateness of care measure.

(b) If an eligible patient receives all indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure and once in the numerator of the SCIP appropriateness of care measure.

(B) The joint commission's stroke measures listed in appendix A to this rule.

(C) The AHRQ's heart and patient safety measures listed in appendix A to this rule.

(D) The centers for disease control and prevention's surgical site infection event measures listed in appendix A to this rule for the following procedures:

(1) CABG with chest incision only;

(2) Cesarean section; and

(3) Knee prosthesis, initial surgery only.

(E) The centers for disease control and prevention's measures for hospital acquired Clostridium difficile and hospital-acquired methicillin resistant and methicillin susceptible staphylococcus aureus bacteremia listed in appendix A to this rule for patients eighteen years of age or older, using the following reporting options, definitions, and specifications of the CDC's national health care safety network:

(1) The laboratory-identified even option;

(2) The facility-wide reporting option with only one denominator for the entire facility; and

(3) The healthcare facility-onset incident definition to calculate the measure.

(F) The infection control information pertaining to influenza vaccination, using the specifications in appendix B to this rule and the information pertaining to the hospital's hand-washing program and infection control staffing specified in appendix C to this rule.

(G) The following pediatric measures:

(1) The joint commission and NQF endorsed children's asthma care measures for systemic corticosteroids for inpatient asthma and relievers for inpatient asthma (ages two to seventeen) overall rate listed in appendix A to this rule; and

(2) Using the specifications prescribed in appendix D to this rule, the following measures listed in appendix E to this rule for patients less than eighteen years of age:

(a) Prophylactic antibiotic received within one hour prior to surgical incision;

(b) Surgical site infection rates for cardiothoracic, neurosurgical and orthopedic procedures; and

(c) Catheter-associated bloodstream infection rate for ICU patients.

(H) Except as otherwise indicated in paragraph (E) of rule 3701-14-03 of the Administrative Code, the perinatal measures listed in appendix E to this rule:

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Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33, 3727.41
Prior Effective Dates: 1/27/2007, 6/28/09