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Hospital Circular 17/1995

Publication Number: 17/1995 Date: 1 July 1995
Distribution: Public Hospitals, Private Hospitals and Day Procedure Centres; Bush Nursing Hospitals
Community Mental Health Services; PRS/2 Interface Software Suppliers
Subject: Definition and Reporting Changes form 1 July1995: Newborns
Purpose: To provide further details in relation to changes to the reporting requirements associated with the Victorian Inpatient Minimum Database (VIMD)

Background

In response to the need to find a more equitable method of funding newborns, and following Extensive consultation with a number of obstetric hospitals, H&CS is revising the mechanism used to fund newborns.

To date, payments for healthy newborns have been included in the mother's delivery case payment. Only newborns who met at least one of the Commonwealth's Criteria for Admission have received a separate case payment.

From 1 July 1995, one payment will be made for each newborn episode, regardless of whether that newborn meets one of these Commonwealth Criteria for Admission. A separate payment will be made for the mother's admission. Both of these payments will be case-mix based.

These alterations are detailed in the document Final Revisions to PRS/2 and the Victorian Inpatient Minimum Database for 1/7/95, distributed to all public and private hospitals and day procedure centres and software suppliers in April 1995, and its addendum, distributed in late June. A separate H&CS circular will address these VIMD changes.

The information contained in this circular formalises advice previously provided to hospitals in a letter dated 31 March 1995 on this subject.

Definitions and parameters for gathering data

In order to gather data to support case payments for all newborns while continuing to meet the State's reporting obligations to the Commonwealth under the Medicare Agreement 1993 - 98, some definitions and parameters used by hospitals in gathering and reporting data to the Victorian Inpatient minimum Database (VIMD) have been revised and three new definitions added.

The data reporting definitions and parameters set out in these documents are effective 1 July 1995, and include those applying to data reporting for newborns.

Four definitions significant in gathering data on newborns are reproduced at Attachment 1.

Funding mechanism

Payments for newborn episodes will be based on data held in the VIMD. Data must be provided on all new borns born on and after 1 July 1995. In addition, data are required on al; newborns remaining in hospital at the end of 30 June 1995. Only one episode may be reported for each such newborn, including one set of diagnosis and procedure codes.

Clinical criteria

A number of clinical criteria have been developed by senior neonatologists for the purpose of this funding mechanism. These clinical criteria serve to differentiate healthy newborns from those requiring more than basic care. A list of ICD-9-CM codes have been collated which identifies these clinical criteria.

Newborn case payments will be based on AN-DRG (v1), with cases grouping to AN-DRG 726 or 727 then further split: cases meeting the clinical criteria will receive a higher payment than those which do not. The clinical criteria are at Attachment 2.

Reporting

In order to concisely report both the original AN-DRG (v1) and whether the clinical criteria are met, PRS and PRS/2 reports will list all newborn case groupings under a heading of 'VICDRG'. This will exclude groups numbered 726 and 727, but include:

Cost Weights

Cost weights to apply from 1 July 1995 are listed in Victoria - Public Hospitals: Policy and Funding Guidelines 1995-96. Section C of this document lists all AN - DRGs (v1) including 726 and 727. Titles listed are those within AN-DRG (v1). The cost weights listed with 726 (0.5000) and 727 (0.3000) will apply to those newborns which, having grouped 726 - 727, 'meet the clinical criteria' and which do not 'meet the clinical criteria', respectively.

That is, a cost weight of 0.5000 will be applied to newborns reported as VICDRG 746 and 747, and a cost weight of 0.3000 will be applied to those reported as VICDRG 748 and 749 on PRS and PRS/2 reports.

Cost weights for obstetric DRGs have also been revised as these no longer include the case payment for the newborn.

Supporting documentation

Clinical documentation and coding guidelines have been developed to assist hospitals in gathering relevant information for new episodes. These are distributed as attachments to this Circular:

Attachment 3 summarises the clinical guidelines for the documentation process.

Attachment 4 details these clinical documentation and coding guidelines.

Attachment 5 sets out the ICD-9-CM codes that define the newborn clinical criteria.

In addition, hospitals will recently have received a letter conveying the Victorian Additions to the Australian Coding Standards, effective 1 July 1995. This supplement includes new ICD-9-CM coding standards for newborns which are in line with the data requirements of the clinical criteria significant for newborn funding.

Qualified and Unqualified newborns

The Commonwealth's Criteria for Admission bear no relation to the clinical criteria developed for the purposes of new funding mechanisms for newborns.

The Commonwealth's Criteria for Admission continue to apply, and are to be used to determine each newborn's Qualification status.

The distinction between newborn's who are Qualified and Unqualified relates to the Commonwealth's Criteria for Admission: a Qualified newborn meets at least one of the Commonwealth's Criteria for Admission, whereas an Unqualified newborn does not.

A newborn may have Qualifies for periods interspersed with Unqualified periods during the same episode. These changes in Qualification Status are not reported as separate episodes, but as changes of Qualification Status within the one episode.

AIMS and Medicare Reporting

A newborn's Qualification Status is significant in determining whether he/she is an admitted patient, and therefore reported as a separation.

A newborn who is a Qualified newborn at ant time during his/her stay is reported as a separation in the relevant account category within the AIMS Forms S1. Patient days are only accrued by a newborn during periods when he/she is a Qualified newborn.

Newborns who are Unqualified for the entire duration of their stay are not reported as separations within the AIMS Forms S1 as Unqualified newborns are not admitted patients under the terms of the Medicare Agreement 1993-98. Hence, days of stay accrued by a newborn during periods when he/she is an Unqualified newborn are not reported as Patient Days within the AIMS Forms S1.

Qualification Status is not relevant in determining level of funding for newborns from 1 July 1995, and there is neither a requirement to admit all newborns, nor an advantage to be gained from this practice.

Election forms

As an Unqualified newborn is not an admitted patient, it I not necessary to complete an election form for those periods within an episode when a newborn is an Unqualified newborn.

However, a separate election form must be completed for every Qualified newborn period. That is, if a newborn has two Qualified periods and one Unqualified period during his/her episode, two separate election forms are required, one for each of the two Qualified periods.

Enquiries

Hospitals should contact their Regional Office for any general enquiries relating to this Circular. Specific enquiries relating to the operation of the PR/2 System may be directed to the H&CS Help Desk on 03 9616 8141.

Please forward a copy of this advice as soon as possible to relevant personnel, including:

Attachments to Circular 17/1995:

Definition and Reporting Changes from 1 July 1995: Newborns

Attachment1: Definitions of Livebirth, Newborn, Qualified Newborn and Unqualified Newborn
Attachment 2: Clinical Criteria for Newborns
Attachment 3: Guidelines for Clinical Documentation fir Newborns
Attachment 4: Clinical Documentation and Coding Guidelines for Clinical Criteria for Newborns
Attachment 5: ICD-9-CM Codes and Clinical Criteria for Newborns

Dr Michael Walsh
Director
Acute Health Services

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