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COMMONWEALTH OF PENNSYVLANIA
DEPARTMENT OF PUBLIC WELFARE
XXXXXXXXXX
W05-2989/922
6/29/2005
7/27/2005
AND NOW, after careful review and consideration of the Recommendation of the Administrative Law Judge, it is
hereby ORDERED that the Recommendation be adopted in its entirety.
Either party to this proceeding has fifteen (15) calendar days from the date of this decision to request reconsideration by the Secretary of the Department. To seek reconsideration, you must fully complete the enclosed application/petition for reconsideration. The application/petition shall be addressed to the Secretary, but delivered to the Director, Bureau of Hearings and Appeals, P.O. Box 2675, Harrisburg, Pennsylvania, 17105-2675, and must be received in the Bureau of Hearings and Appeals within fifteen (15) calendar days from the date of this Order. This action does not stop the time within which an appeal must be filed to Commonwealth Court. The appropriate party(ies), where permitted, may take issue with this Adjudication, and Order, and may appeal to the Commonwealth Court of Pennsylvania, within thirty (30) days from the date of this order. This appeal must be filed with the Clerk of Commonwealth Court of Pennsylvania, Room 624, Irvis Office Building, Harrisburg, Pennsylvania 17120. If you file an appeal with the Commonwealth Court, a copy of the appeal must be served on the government unit which made the determination in accordance with Pa. R.A.P. 1514. In this case, service must be made to: Department of
Public Welfare, Bureau of Hearings and Appeals, 2330 Vartan Way, 2nd Floor, Harrisburg, Pennsylvania 17110-9721,
AND Department of Public Welfare, Office of Legal Counsel, Room 309 Health & Welfare Building, Harrisburg, PA 17120.
Final Administration Action and Mailing Date Thomas E. Cheffins, Chief Administrative Law Judge cc: XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE

APPEAL OF:
RECOMMENDATION
It is hereby Recommended that the appeal of Appellant should be SUSTAINED. The
Department should be directed to reimburse the Appellant for the entire admission of the patient, from April 19, 2004 to May 5, 2004, the date of discharge. September 30, 2005 ______________________________ Date COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE

APPEAL OF:
ADJUDICATION

OPENING STATEMENT

This is an adjudication on the appeal of Pittsburgh Mercy Health System, Appellant, from a determination by the Department of Public Welfare - Bureau of Program Integrity (Department), which denied reimbursement retrospectively for part of the admission of the patient, due to a lack of medical necessity. A telephone hearing was convened on September 27, 2005 at 2:20 p.m. from the Bureau of Hearings and Appeals, 117 West Main Street, Plymouth, Pennsylvania. All witnesses were sworn and testified under oath. Biagio V. Musto, II, Esquire, Administrative Law Judge, presided.
EXHIBITS

For the Department:
July 12, 2005 appeal, received July 27, 2005 Whether the Department correctly denied reimbursement retrospectively for part of the psychiatric admission of the patient, from May 2, 2004 through May 5, 2004, due to a lack of medical
necessity.
FINDINGS OF FACT

1.
The Appellant admitted the patient to its psychiatric hospital on April 19, 2004 and discharged the patient on May 5, 2004. (Exhibit C-3 and Testimony of DW) The patient was a 22 year old male with a history of psychosis. (Exhibit C-3 and Testimony of DW) On the day of admission, the patient was involuntarily committed based upon a petition filed by his mother. (Exhibit C-3 and Testimony of DW) The patient had been involuntarily committed due to the fact that he had become increasingly psychotic and was unable to care for himself. (Exhibit C-3 and Testimony of DW) The patient had become increasingly psychotic due to the fact that he stopped taking his medications, prior to admission. (Exhibit C-3 and Testimony of DW) During this admission, the Appellant placed the patient on Haldol to prepare the patient to be treated with an injectable form of that medication. (Exhibit C-3 and Testimony of DW) The injectable form of Haldol is used for patients who are non-compliant with medications, and the effects of that medication lasts for several weeks. (Exhibit C-3 and Testimony of DW) The Appellant administered an injection of injectable Haldol for the patient on April 30, 2004. (Exhibit C-3 and Testimony of DW) When using injectable Haldol, it is important to wait five days to determine whether the patient has reached an appropriate stabilized state through the use of that medication. (Exhibit C-3 and Testimony of AW) The Appellant waited five days after injecting Haldol into the patient on April 30, 2004, and discharged the patient on May 5, 2004, in good condition. (Exhibit C-3 and Testimony of AW) As of May 2, 2004, the patient had some remaining auditory and visual hallucinations. (Exhibit C-3 and Testimony of AW) The patient did not have any active hallucinations on May 5, 2004, and therefore was discharged from the psychiatric hospital. (Exhibit C-3 and Testimony of AW) On June 29, 2005, the Department denied reimbursement retrospectively for part of the admission of the patient, the period from May 2, 2004 through May 5, 2004, due to a lack of medical necessity. (Exhibit C-1) The Appellant filed an appeal which was dated July 12, 2005 and received on July 27, 2005. (Exhibit C-2)
DISCUSSION

The Appellant appealed from a determination by the Department denying reimbursement retrospectively for part of the admission of the patient, due to a lack of medical necessity. The Department denied reimbursement for part of the admission of the patient by notice dated June 29, 2005, and the Appellant filed a timely appeal, which was received on July 27, 2005. The Department’s representative argued the period of psychiatric hospitalization, from May 2, 2004 through May 5, 2004, was not medically necessary. The Department’s representative argued that the patient could have been treated in a lesser level of care beginning on May 2, 2004, due to the fact that his condition had stabilized. The Appellant’s representative argued that the patient required psychiatric hospitalization until May 5, 2004, to determine whether his treatment with injectable Haldol was working appropriately. The Appellant’s representative also argued that the patient continued to have active hallucinations on May 2, 2004. Medical Assistance Regulations state that the Department pays for compensable services or items rendered, prescribed or ordered by a practitioner or provider if the service or item is within the practitioner’s scope of practice, medically necessary, not in an amount that exceeds the recipient’s needs, not ordered or prescribed solely for the recipient’s convenience and is ordered with the recipient’s knowledge. 55 Pa. Code §1101.66. The term medically necessary is defined as a service, item, procedure or level of care that is compensable under the Medical Assistance Program, necessary to the proper treatment or management of an illness, injury or disability and is prescribed, provided or ordered by an appropriate licensed practitioner in accordance with standards of practice. 55 Pa. Code §1101.21. Standards of practice are referenced in 55 Pa. Code §1101.51 which states that in addition to licensing standards, every practitioner providing medical care to MA recipients is required to adhere to the basic standards of practice listed in the subsection. Payment will not be made when the Department’s review of a practitioner’s medical records reveals instances where these standards have not been met. Additionally, these standards of practice require that a proper record shall be maintained for each patient and that the record shall contain documentation of the medical necessity of a rendered, ordered or a prescribed service. 55 Pa. Code §1101.51 (d) (1) and (e) (x). Specifically, as to inpatient psychiatric facilities, the Department will not pay an inpatient psychiatric facility for custodial care (either related or unrelated to court commitments) unless medical necessity exists for psychiatric inpatient care. Unnecessary admissions and days of care due to conditions which do not require psychiatric inpatient care are not compensable. 55 Pa. Code §1151.48 (a) (7) and (9). The Department will not pay an inpatient psychiatric facility for days of care for recipients who no longer require psychiatric inpatient care or for grace periods, such as pending discharge of a recipient when inpatient hospital care is no longer needed. 55 Pa. Code §1151.48 (a) (10) and (12). Also, the day of discharge is non-compensable unless it is also the day of admission. 55 Pa. Code §1151.48 (a) (18). The Department also will not pay an inpatient psychiatric facility for days of inpatient care provided to a recipient who is suitable for an alternate type or level of care, regardless of whether the recipient is under voluntary or involuntary commitment. 55 Pa. Code §1151.48 (a) (15). 55 Pa. Code §1151.48 (b) and (c) state that the Department will not pay inpatient psychiatric facilities for services or items in sub-section (a) or for services or items provided in conjunction with the provision of a service or item in sub-section (a) even if the attending physician or Hospital Utilization Review Committee determines that the stay was medically necessary. In this case, the Department’s denial was incorrect. The Appellant treated the patient with injectable Haldol on April 30, 2004. In order to determine whether that medication is appropriately working, a patient should be observed for approximately five days. Allowing the Appellant five days to observe the patient’s condition to determine whether injectable Haldol was working would result in admission of the patient until May 5, 2004, which was the actual date of discharge in this case. Therefore, the Appellant’s action in continuing to hospitalize the patient until May 5, 2004 was reasonable and medically necessary for the condition of the patient. Additionally, the patient continued to have some active hallucinations as of May 2, 2004, and his psychosis had not completely resolved. By the time of discharge, injectable Haldol was working appropriately, and the patient was not having any continued psychosis. As such, admission until May 5, 2004 was medically necessary and appropriate. The Department’s representative argued that the patient could have been discharged on May 2, 2004, due to the fact that his condition had resolved after being injected with Haldol. However, as noted above, the Appellant’s actions in waiting a few more days to discharge the patient were appropriate, due to the fact that it takes a certain period of time to observe the results of injectable Haldol and the fact that the patient continued to exhibit some psychosis on May 2, 2004. Accordingly, Appellant’s appeal should be sustained. The Department should be directed to reimburse the Appellant for the entire admission of the patient, from April 19, 2004 through May 5, 2004, the date of discharge. A recommendation to the Chief Administrative Law Judge will be made consistent with these

Source: http://services.dpw.state.pa.us/olddpw/Decisions/003776383.pdf

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