CurrentAmerigroupPolicy G-20003

Provider Preventable Conditions

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Defines Amerigroup's reimbursement stance for provider preventable conditions (PPCs), including Health Care-Acquired Conditions (HCAC) and Other Provider Preventable Conditions (OPPC), and billing/reporting requirements for inpatient facility claims; applies to providers submitting claims to Amerigroup Community Care.

Policy Summary

PayerAmerigroup

PolicyProvider Preventable Conditions

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date03/22/2023

Next Review DateN/A

Key ActionSubmit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses; failure may result in claim denial or rejection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POA requiredPOA requirement

Member held harmlessMember billing

14 categoriesHCAC list

Certain facilitiesPOA exemptions

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CurrentAmerigroupPolicy G-20003

Provider Preventable Conditions

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Policy Summary

PayerAmerigroup

PolicyProvider Preventable Conditions

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date03/22/2023

Next Review DateN/A

Key ActionSubmit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses; failure may result in claim denial or rejection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POA requiredPOA requirement

Member held harmlessMember billing

14 categoriesHCAC list

Certain facilitiesPOA exemptions

PPC coverage criteria

Covered with conditions — Amerigroup does not reimburse for Provider Preventable Conditions (PPC) except where provider, state, federal, or CMS contracts or requirements indicate otherwise. Coverage and operational rules for HCACs and OPPCs are below:

ALL of the following

Amerigroup does not reimburse for Provider Preventable Conditions (PPC) unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.
Source: policy definition of PPC (HCAC and OPPC)

ALL of the following

POA indicators are required for all inpatient primary and secondary diagnoses; failure to include POA with primary and secondary diagnosis codes may result in claim denial or rejection.
Submit POA for all inpatient primary and secondary diagnoses; POA not required on admitting diagnosis.
If POA identifies a HCAC, related charges and/or days shall be removed from the claim when calculating DRG reimbursement; reimbursement follows Medicare POA methodology.
HCAC charges/days excluded from DRG calculations; reimbursement based on Medicare POA methodology.
It is possible to have multiple CCs or MCCs on a claim; only CCs/MCCs identified as HCACs will be excluded when calculating the DRG; non-HCAC CCs/MCCs may result in a higher paying DRG.
Only HCAC CCs/MCCs excluded; non-HCAC may increase DRG.
Reimbursement will not be reduced or denied if the HCAC existed prior to initiation of treatment by that facility; if a HCAC is caused by one facility, payment will not be denied to a secondary facility that treated the HCAC.
Existing-condition and secondary facility protections.
Amerigroup will adopt any future HCAC categories/conditions or grouper algorithm changes recognized by CMS or the state.
Automatic adoption clause.

ALL of the following

OPPCs are defined as surgical or invasive procedures erroneously performed (wrong body part, wrong patient, wrong surgery).
OPPC categories per CMS-aligned definitions.
Procedures identified as OPPCs, and all related services for professional providers and facilities, will be rejected or denied.
OPPCs and related services are nonreimbursable for both professional providers and facilities.
Erroneous surgical events occurring during an inpatient stay should be reflected on Type of Bill 0110 (no-pay claim) along with all services or procedures related to the surgery; all other inpatient procedures and services should be submitted on a separate claim.
Billing instruction for inpatient OPPC events.
A condition defined as an OPPC that existed prior to initiation of treatment by another provider will not impact that provider's reimbursement.
Existing-condition protection for OPPCs.

ALL of the following

Neither the professional provider nor facility may seek payment from the member for nonreimbursable services related to a PPC; the member must be held harmless.
Member held harmless requirement.
Amerigroup reserves the right to request additional records from the professional provider or facility; claims may be subject to clinical review for appropriate reimbursement consideration.
Documentation and review may be requested.

ALL of the following

Providers should use the appropriate codes to report OPPCs (e.g., ICD-10 Y65.53, Y65.52, Y65.51) and the PC modifier denotes Wrong Surgery on a Patient and should not be used to represent the professional component of a service.
Related coding descriptions and PC modifier guidance.
Claims that incorrectly use the PC modifier may be denied; denied claims may be resubmitted as corrected claims with appropriate coding.
Incorrect modifier use may lead to denial; resubmission required if corrected.

Provider Billing, Reporting, and Documentation Requirements

Documentation Required

POA indicators and OPPC inpatient billing requirements

Submit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses; failure to include the POA indicator with the primary and secondary diagnosis codes may result in the claim being denied or rejected. For inpatient erroneous surgical events (OPPC), bill the inpatient event on Type of Bill 0110 (no‑pay claim) and bill related services on separate claims. Amerigroup may request additional records and claims may be subject to clinical review for reimbursement consideration.

POA indicators are required for all inpatient primary and secondary diagnoses; POA is not required on the admitting diagnosis. (see Exhibit A)
If POA identifies an HCAC, related charges/days will be removed from DRG reimbursement calculations.
OPPC inpatient erroneous surgical events should be reflected on Type of Bill 0110 (no‑pay claim); related services billed separately.
Amerigroup may request additional records; claims may be subject to clinical review.

Key Definitions

Provider Preventable Conditions (PPC), HCAC, OPPC — Definitions

Provider Preventable Conditions (PPC)Conditions identified as Health Care-Acquired Conditions (HCAC) or Other Provider Preventable Conditions (OPPC); Amerigroup does not reimburse for PPCs unless contracts or requirements indicate otherwise.

Health Care-Acquired Conditions (HCAC)Conditions not present at admission that develop during the hospital stay; identified via POA reporting and enumerated in Exhibit C for exclusion from DRG calculations.

Other Provider Preventable Conditions (OPPC)Erroneous surgical or invasive procedure events (wrong body part, wrong patient, wrong surgery). Procedures and all related services for OPPCs will be rejected or denied; inpatient erroneous surgical events should be billed on Type of Bill 0110 (no-pay claim) with related services on separate claims.

Adoption of CMS definitionsAmerigroup defines OPPCs and adopts procedures/categories recognized by CMS; OPPC definitions and handling align with CMS contracts and requirements.

Present on Admission (POA) indicators — Definitions and meanings

YDiagnosis was present at time of inpatient admission.

NDiagnosis was not present at time of inpatient admission.

U/WClinically undetermined or documentation insufficient to determine if condition was present at the time of inpatient admission.

1Unreported/Not used — Exempt from POA reporting; equivalent to a blank on the UB-04 (used where applicable).

Provider Preventable Conditions

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Provider Preventable Conditions

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Provider Preventable Conditions Coverage

Billing and Codes for OPPC/HCAC

Provider Billing, Reporting, and Documentation Requirements

Key Definitions

PC	Modifier for Wrong Surgery on a Patient (should not be used to represent professional component)
Y65.53	ICD-10: Surgical or invasive procedure on the wrong body part
Y65.52	ICD-10: Surgical or invasive procedure on the wrong patient
Y65.51	ICD-10: Wrong surgery or invasive procedure on patient