§ 1163.2. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
APR-DRG—All Patient Refined Diagnosis Related Group.
Buildings—The basic structure or shell and additions thereto.
Children’s hospital—A hospital in which 50% or more of the inpatients are 17 years of age or younger.
DRGs or diagnosis related groups—A patient classification system that reflects clinically cohesive groupings of patients that consume similar amounts of hospital resources.
Day of inpatient hospital care—Room, board and professional services furnished to a patient on a continuous 24-hour-a-day basis in a semi-private room of a hospital. The term includes items and services ordinarily furnished by the hospital for the care and treatment of inpatients provided in an institution other than one maintained primarily for treatment and care of patients with tuberculosis or mental disease.
Fixtures—Attachments to buildings such as wiring, electrical fixtures, plumbing, elevators, heating systems, air conditioning systems and the like. The general characteristics of fixtures are that they are affixed to the building and not subject to transfer and that they have a fairly long life, but shorter than the life of the building to which they are affixed.
Hospital—A facility licensed as a hospital under 28 Pa. Code Part IV, Subpart B (relating to general and special hospitals) which provides equipment and services primarily for inpatient care to persons who require treatment for injury, illness, disability or pregnancy. The term does not include rehabilitation hospitals, public or private psychiatric hospitals, drug and alcohol rehabilitation hospitals, general nursing facilities, hospital-based nursing facilities, county-operated nursing facilities, intermediate care facilities for the mentally retarded, psychiatric transitional facilities or special rehabilitation nursing facilities.
Hospital admission—The formal acceptance of a patient to a hospital inpatient setting for purposes of providing inpatient hospital services.
Inpatient hospital services—Services, other than those provided by an institution for tuberculosis or mental diseases, which are ordinarily furnished in a hospital for the care and treatment of inpatients. Inpatient hospital services exclude services provided in a short procedure unit, direct care practitioners’ services and direct care midwives’ services. Inpatient hospital services are furnished under the direction of a licensed physician, dentist, podiatrist or nurse-midwife.
Institutionalized individual—A person who is detained or confined under one of the following:(i) A civil or criminal statute in a correctional, rehabilitative or mental retardation facility, psychiatric hospital or other facility for the care and treatment of mental illness or mental retardation.
(ii) Voluntary commitment in a psychiatric hospital, mental retardation facility or other facility for the care and treatment of mental illness or mental retardation.
Normal newborn—A liveborn neonate whose diagnosis is categorized into severity level 1 of the newborn APR-DRG 640 as of July 1, 2011.
Outlier—An inpatient hospital case having either an extremely long length of stay or extraordinarily high costs in comparison to most discharges for the same DRG.
Patient pay amount—Income or assets that a recipient has available to meet the cost of medical care as determined by the CAO. The recipient, not the MA Program, pays this amount toward the cost of care.
Therapeutic leave—A period of absence from the hospital related to the treatment of an individual’s illness.
Authority The provisions of this § 1163.2 amended under sections 201(2), 403(b) and 403.1 of the Public Welfare Code (62 P. S. § § 201(2), 403(b) and 403.1).
Source The provisions of this § 1163.2 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 June 1, 1990, effective retroactively to April 1, 1987, 20 Pa.B. 2913; 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 pages (337500) and (201283).
Notes of Decisions This section supports the Department’s decision to deny reimbursement to a hospital which admitted patient overnight for treatment which could have safely been rendered in Special Procedure Unit. Episcopal Hospital v. Department of Public Welfare, 528 A.2d 676 (Pa. Cmwlth. 1987).
Although patient was in hospital less than 24 hours, this does not disqualify from inpatient reimbursement. The phrases ‘‘continuous 24 hour a day basis’’ means only that care provided must be of the type that is provided on a continuous 24-hour-a-day basis. Further, in the absence of specific legislative or regulatory action there is no authority for pro-ration. Frankford Hospital v. Department of Public Welfare, 492 A.2d 1179 (Pa. Cmwlth. 1985).
Cross References This section cited in 55 Pa. Code § 1151.54 (relating to disproportionate share payments); 55 Pa. Code § 1163.51 (relating to general payment policy); 55 Pa. Code § 1163.52 (relating to prospective payment methodology); 55 Pa. Code § 1163.67 (relating to disproportionate share payments); and 55 Pa. Code § 1163.459 (relating to disproportionate share payments).
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