Policy Statement
Our health plan believes that when a member enters a facility for treatment of a medical problem, the member should not experience a preventable adverse event during the member’s stay. Accordingly, our health plan expects all providers to take proper precautions to ensure a preventable adverse event does not occur.
Our health plan will not reimburse providers for a preventable adverse event. All providers are required to hold members harmless for any services related to preventable adverse events. As part of our health plan’s commitment to improving the quality of care available to members, we have adopted reimbursement policies that encourage providers to reduce the incidence of preventable adverse events.
Some examples of preventable adverse events (this list is not all inclusive of indications which may be reviewed in accordance with the reimbursement policy):
- Certain surgical site infections.
- Error in the dose or administration of a drug.
- Nosocomial infections (also known as a hospital acquired infection).
- Surgical adverse event that could have reasonably been prevented with a change in surgical technique or clinical judgement.
Non-reimbursable procedures/services include but are not limited to:
- All adverse event related services provided in the operating room when the initial planned procedure is not completed are considered not reimbursable.
- All adverse event related services provided during the same or subsequent facility stay/visit are not reimbursable.
- Providers should note that an adverse event related services do not include performance of the procedure [(i.e. originally planned and completed procedure(s)].
When a preventable adverse event occurs, the case will be reimbursed as though the secondary preventable adverse event diagnosis is not present. We will consider reimbursement for services not related to preventable adverse events if itemized statements are submitted with the claim.
Our health plan will consider reimbursement for anticipated preventable adverse events occurring with high-risk non-elective procedures, such as repair of major trauma.
If the provider was not the primary provider performing the service causing the preventable adverse event and/or the provider where the preventable adverse event occurred, providers will be reimbursed for costs incurred to treat the preventable adverse events.
Our health plan requires diagnosis codes on all provider claims in order to determine if a preventable adverse event occurred, as mandated by official coding guidelines.
The relevant ICD diagnosis code for an ‘external cause of injury code’ is required to be submitted on all applicable claims as the diagnosis in the secondary position to indicate that a preventable adverse event has occurred.
Providers are required to submit a Present on Admission (POA) Indicator on all claims in which a preventable adverse event occurred. POA indicators are assigned to the principal and secondary diagnoses.
POA Indicator Options and Descriptions:
- N = Diagnosis was not present at the time of inpatient admission.
- U = Documentation insufficient to determine if the condition was present at the time of inpatient admission.
- W = Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.
- Y = Diagnosis was present at the time of inpatient admission.
The following are exempt from the POA indicator options above, but can still be reviewed for potential preventable adverse events:
- Critical Access Hospitals paid on a per-diem
- Inpatient Rehabilitation Facilities
- Long Term Care Hospitals
Never Event/Sentinel Event/Serious Reportable Event (SRE) includes, but are not limited to:
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgery performed on a patient
Preventable adverse events includes, but are not limited to:
- Air Embolism
- Blood Incompatibility
- Catheter-Associated Urinary Tract Infection (UTI)
- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
- Hip Replacement
- Total Knee Replacement
- Falls and Trauma
- Burn
- Crushing Injuries
- Dislocations
- Fractures
- Intracranial Injuries Other Injuries
- Foreign Object Unintentionally Retained After Surgery
- Iatrogenic Pneumothorax with Venous Catheterization
- Manifestations of Poor Glycemic Control
- Diabetic Ketoacidosis
- Hypoglycemic Coma
- Nonketotic Hyperosmolar Coma
- Secondary Diabetes with Hyperosmolarity
- Secondary Diabetes with Ketoacidosis
- Stage III and IV Pressure Ulcers
- Surgical Site Infection Following Bariatric Surgery for Obesity
- Gastroenterostomy
- Laparoscopic Gastric Bypass
- Laparoscopic Gastric Restrictive Surgery
- Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
- Surgical Site Infection Following Certain Orthopedic Procedures
- Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)
- Vascular-Catheter Associated Infection
The Appendix A table below is the Centers for Medicare & Medicaid (CMS) Hospital Acquired Conditions list. This list of hospital acquired conditions is not all inclusive.
APPENDIX A
