In addition to the general requirements in §354.1001 of
this subchapter (relating to Claim Information Requirements), HHSC
requires that the following information be submitted with hospital
claims:
(1) Inpatient hospital care.
(A) Copy of the patient's itemized daily charges, including
data elements and format as specified by HHSC.
(B) Date and hour of admission and discharge, including
inclusive dates during which services were provided if claims are
made for a period other than that beginning on the date of admission
and ending with the date of discharge.
(C) Number of days of care.
(D) Charges for bed, meals, and nursing care.
(E) Admitting diagnoses or symptoms.
(F) Discharge diagnoses (or diagnoses at end of period
for which a claim is made if discharge has not occurred).
(G) Surgical procedures, if any.
(H) Individual charges for ancillary services approved
by HHSC.
(I) Dates on which the various types of services were
provided. The posting date is satisfactory except when a portion of
the period of care precedes or succeeds the certified period of eligibility.
In such cases, record the actual date that each of the types of services
listed in this paragraph was provided.
(J) Certification by the hospital that the hospital
has on file a record that services provided were upon order of a physician
or doctor, a record of admission, continued stay certification, extension
recertification, and 60-day recertification.
(K) The hospital's medical record number.
(L) The name, address, and appropriate identification
number of the attending physician and, if appropriate, consulting
physician(s) or doctor(s).
(M) The certification portion of the Texas Admissions
and Review Program (TARP) abstract must accompany claims from all
certified hospitals. The entire abstract must accompany claims from
noncertified hospitals.
(N) For medically necessary hysterectomies, a patient's
acknowledgment statement that the person who secured authorization
to perform the hysterectomy has informed the patient and her representative,
if any, orally and in writing, that the hysterectomy renders the patient
permanently sterile. The patient or her representative, if any, must
sign the written acknowledgment of receipt of that information before
the surgery. The provider must submit an acknowledgment statement
with hospital claims for hysterectomies unless the patient is sterile
at the time of the hysterectomy, or the patient requires a hysterectomy
on an emergency basis because of a life-threatening situation and
the physician determines that prior acknowledgment is not possible.
If one of the exceptions applies, the physician performing the hysterectomy
must certify in writing, to HHSC or its designee, that the specific
circumstance existed at the time he or she operated.
(O) Present on admission indicators are required for
all inpatient claims.
(2) Hospital outpatient services.
(A) Surgical procedure(s) related to each specific
diagnosis, where possible.
(B) Medical treatment(s) related to each specific diagnosis,
where possible.
(C) Diagnosis(es).
(D) Charges for each service.
(E) Date of each service.
(F) Name, address, and appropriate identification number
of the attending physician and (if known) of ordering and consulting
physician(s).
(3) An erroneous surgery, procedure, or treatment that
is classified by HHSC as a preventable adverse event must be submitted
with the appropriate modifier, as defined by HHSC or its designee,
on all lines related to the erroneous surgery, procedure, or treatment.
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Source Note: The provisions of this §354.1071 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 6, 1979, 4 TexReg 478; amended to be effective August 4, 1982, 7 TexReg 4162; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 1, 2010, 35 TexReg 6649; amended to be effective August 6, 2013, 38 TexReg 4886 |