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Inpatient Rate Reform Questions and Answers

Select the Frequently Asked Question to view answer.

What is the effective date of inpatient rate reform?
For inpatient claims, it is discharge dates on or after 07/01/14.
Who is excluded from the APR-DRG system?
Psychiatric hospitals and distinct part units; rehabilitation hospitals and distinct part units; Long Term Acute Care (LTAC) hospitals; children’s specialty hospitals with less than 50 beds; non-cost reporting out-of-state hospitals; hospitals owned by and located in an Illinois county with a population exceeding three million; and hospitals organized under the University of Illinois Hospital Act are all excluded and will continue to be paid on a per diem basis.
Beginning on 07/01/14, what version of the APR-DRG will be used by the department?
Grouper Version 30 of the 3M™ All Patient Refined Diagnosis Related Group (APR-DRG) payment system.
Are children’s hospitals required to get a new HFS Provider Id number?
No, children’s hospitals that will no longer be paid per diem for their general inpatient care will continue to use their current HFS provider id.
What if interim claims were paid per diem for dates of service prior to 07/01/14 but now are paid APR-DRG?
Any discharge on or after July 1, 2014 will be processed and reimbursed under the APR-DRG system. For hospitals that will be reimbursed under APR-DRG beginning July 1st, any interim claims that have been paid with dates of service prior to July 1st must be voided and the entire admission rebilled as an admission through discharge claim after the patient is discharged.
Will normal newborn claims continue to be reimbursed on the mother’s claim?
No, normal newborns’ claims will now be processed and paid separately from the mothers’ claims, and will be eligible for disproportionate share payments if applicable.
Is the birth weight still required for newborn claims?
Yes, Value Code 54 is required for newborns who are 14 days of age or less on the date of admission. This Value Code is to be reported with the baby’s birth weight in grams, right-justified to the left of the dollar/cents delimiter, and will be used in the APR-DRG determination. Claims that do not have this value reported will be rejected.
Any changes for billing transplants claims?
Inpatient transplants will be billed admission through discharge on one claim. Transplant claims still must be submitted to the transplant coordinator with the exception of kidney and cornea.
Will hospitals be required to use modifiers?
Hospitals are required to bill modifiers according to the national coding guidelines. Incorrect billing of modifiers may affect the payment to the hospitals.


Hospital Rate Reform Initiative

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Illinois Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director