Provider Notice issued 06/30/12

Changes to Utilization Reviews/Inpatient Detoxification Readmissions

To:​ Participating Hospitals – Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers, and Utilization Review Departments
​Date: ​June 30, 2012
​Re: Changes to Utilization Reviews/Inpatient Detoxification Readmissions​

As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department is implementing the following utilization review changes specific to inpatient level of care for detoxification readmissions.

Effective with admissions on or after July 9, 2012, HFS will implement a review of inpatient detoxification admissions 60 days prior to July 9, 2012, for the detoxification diagnosis codes that currently require mandatory concurrent review and are identified below. Inpatient detoxification admission stays will not be approved for reimbursement if there has been a previous inpatient detoxification stay within the last 60 days. The admitting inpatient facility should contact eQHealth within 24 hours or the next business day of the admission to begin the concurrent review process.

Effective July 9, 2012, a Detoxification Look-Up utility will be available to providers to check inpatient detoxification admission status. This utility will be available solely through eQHealth’s Web system, eQSuite™, as it offers 24/7 availability and a majority of providers already have access to eQSuite™. If hospital staff needs access to eQSuite™, they should contact their eQHealth Web Administrator.

  • eQHealth Look-Up Utility

If there was an admission within the past 60 days, the message will read:

Participant is not eligible for a detox admission for the proposed admit date due to a previous inpatient detoxification stay within 60 days.

If there was no admission with the past 60 days, it will read:

Participant is eligible for a detox admission for the proposed admit date. Submit your review request via the Web or Certification line within 24 hours of admission or the next business day.

The applicable message will be shown in a pop-up that also contains the beneficiary ID entered in the look-up and the last detoxification admission date as shown below:

Bene ID: 1234567

Last detox admission date: 6/15/2012

Participant is not eligible for a detox admission for the proposed admit date.

A provider notice from eQHealth will be sent next week with instructions/screen shots to use this new utility. eQHealth will also offer 15-minute Webinars throughout the day on July 5th and 6th, for those who prefer a quick tutorial. Hospitals may register for the eQHealth tutorial under the Announcement section of the eQHealth Web site or e-mail eQHealth.

When a diagnosis code is subject to review and ICD-9-CM coding guidelines mandate a coding change requiring a 4th or 5th digit code extension, the 4th and 5th digit code extension will automatically be subject to review.

The following diagnosis codes are currently part of the Mandatory Concurrent Review Process that is administered by HFS and its Quality Improvement Organization, eQHealth:

Diagnosis Code

Description

290.0

Senile dementia, uncomplicated

290.10

Presenile dementia, uncomplicated

290.11

Presenile dementia with delirium

290.12

Presenile dementia with delusional features

290.13

Presenile dementia with depressive features

290.20

Senile dementia with delusional features

290.21

Senile dementia with depressive features

290.3

Senile dementia with delirium

290.40

Vascular dementia, uncomplicated

290.41

Vascular dementia, with delirium

290.42

Vascular dementia, with delusions

290.43

Vascular dementia, with depressed mood

290.8

Other specified senile psychotic conditions

290.9

Unspecified senile psychotic condition

291.0

Alcohol withdrawal delirium

291.1

Alcohol-induced persisting amnestic disorder

291.2

Alcohol-induced persisting dementia

291.3

Alcohol-induced psychotic disorder with hallucinations

291.4

Idiosyncratic alcohol intoxication

291.5

Alcohol-induced psychotic disorder with delusions

291.81

Alcohol withdrawal

291.82

Alcohol-induced sleep disorder

291.89

Other specified alcohol-induced mental disorders

291.9

Unspecified alcohol-induced mental disorders

292.0

Drug withdrawal

292.11

Drug-induced psychotic disorder with delusions

292.12

Drug-induced psychotic disorder with hallucinations

292.2

Pathological drug intoxication

292.81

Drug-induced delirium

292.82

Drug-induced persisting dementia

292.83

Drug-induced persisting amnestic disorder

292.84

Drug-induced mood disorder

292.85

Drug-induced sleep disorder

292.89

Other

292.9

Unspecified drug-induced mental disorder

This informational notice also provides notification of changes to diagnosis codes subject to admission/concurrent inpatient utilization review.

  • Changes in Diagnosis Codes on Attachment B

Effective with admissions on and after August 1, 2012, the following Diagnosis Codes are subject to mandatory concurrent review and will be added to Attachment B and will be subject to the 60 day readmission policy for detoxification:

Diagnosis Code

Description

3030

Acute Alcohol Dependence Syndrome

30300 – 30303

 

30390 - 30393

 

3050    

Alcohol Abuse

30500 - 30503

 

30400 – 30403

Drug Dependence

30410 – 30413

Sedative, hypnotic or anxiolytic dependence

30420 – 30423

Cocaine Dependence 

30430 – 30433

Cannabis Dependence

30440 – 30443

Amphetamine and other Psychostimulant Dependence

30450 – 30453

Hallucinogen Dependence

30460 – 30463

Other Specified Drug Dependence

30470 – 30473

Combinations of Opioid type drug with any other

30480 – 30483

Combinations of drug dependence excluding opioid type drug

30490 – 30493

Unspecified drug dependence

30520 – 30523

Cannabis Abuse

30530 – 30533

Hallucinogen Abuse

30540 – 30543

Sedative, hypnotic or anxiolytic abuse

30550 – 30553

Opioid abuse

30560 – 30563

Cocaine abuse

30570 – 30573

Amphetamine or related acting sympathomimetic abuse  

30580 – 30583

Antidepressant type abuse

30590 – 30593

Other, mixed or unspecified drug abuse

7903

Excessive Blood Level of Alcohol

 

  • Exceptions to Mandatory Concurrent Review Will Apply

The department will allow limited exceptions to mandatory concurrent review in the following circumstances:

    • A participant’s eligibility was backdated to cover the hospitalization.

    • Medicare Part A coverage exhausted while the patient was in the hospital, but the hospital was not aware that Part A exhausted.

    • Discrepancies associated with the patient’s Managed Care Organization (MCO) enrollment at the time of admission.

    • The patient remains unresponsive or has a physical or mental impairment during the hospitalization that prevents the hospital from identifying coverage under one of the department’s medical programs.

    • Other – the hospital must provide narrative description.

Attachments A through D can be downloaded from the department’s Peer Review Organization (PRO) / Quality Improvement Organization (QIO) Web site.

Any questions regarding the review process may be directed to eQHealth at the toll-free Helpline at 1-800-418-4045. Any questions regarding this notice may be directed to the Bureau of Maternal and Child Health Promotion at 217-557-5438.

Theresa A. Eagleson, Administrator

Division of Medical Programs