CurrentAnthemPolicy G-20003

Provider Preventable Conditions (PPC) — Reimbursement Policy

Defines Anthem Medicare Advantage reimbursement rules for Provider Preventable Conditions (including Health Care-Acquired Conditions and Other Provider Preventable Conditions) and billing/reporting requirements for inpatient facility and professional claims affected; applies to providers submitting claims for Anthem Medicare Advantage members in specified states.

Policy Summary

PayerAnthem

PolicyProvider Preventable Conditions (PPC) — Reimbursement Policy

Policy CodePolicy G-20003

Change TypeNon‑material clarifying update

Effective DateMar 22, 2023

Next Review DateN/A

Key ActionSubmit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses to avoid claim denial or rejection.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language on the HCAC algorithm and updated the title from Preventable Adverse Events to Provider Preventable Conditions.

11HCAC categories

POA requiredPOA requirement

Held harmlessMember billing

Exempt listExempt facilities

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PPC coverage and claim rules

Anthem Medicare Advantage reimbursement stance and claim handling rules for Provider Preventable Conditions (PPC):

Anthem Medicare Advantage does not reimburse for Provider Preventable Conditions (PPC) unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

PPCs include Health Care-Acquired Conditions (HCAC) and Other Provider Preventable Conditions (OPPC).

HCAC identification: a Present on Admission (POA) indicator must be submitted for all inpatient primary and secondary diagnoses; POA is not required on the admitting diagnosis. Failure to include required POA indicators may result in claim denial or rejection.

When a diagnosis is identified as a HCAC (POA = not present), charges and/or days related to the HCAC shall be removed from the claim when calculating DRG reimbursement; non-DRG reimbursement may also be reduced. Anthem reimburses using the CMS MS-DRG algorithm and will adopt future CMS/state HCAC categories or grouper changes.

OPPCs are erroneous surgical events (wrong body part, wrong patient, wrong surgery). Procedures and all related services identified as OPPCs for professional providers and facilities will be rejected or denied.

Inpatient erroneous surgical events should be submitted on Type of Bill 0110 (no-pay claim) with all services or procedures related to the surgery on that claim; other inpatient procedures and services should be submitted on separate claims.

Providers must use appropriate codes and modifiers to report OPPCs (ICD-10 examples include Y65.51, Y65.52, Y65.53 and modifiers PA/PB/PC as applicable); incorrect use of modifiers (e.g., PC) may result in denial and require corrected claim resubmission.

Providers may not seek payment from the member for nonreimbursable services related to a PPC; the member must be held harmless.

Anthem may request additional records and subject claims to clinical review to support documentation for PPCs and determine appropriate reimbursement.

A condition defined as a HCAC or OPPC that existed prior to the initiation of treatment by a facility/provider will not reduce or deny reimbursement to that provider; if a HCAC is caused by a primary facility, payment will not be denied to a secondary facility that treated the HCAC.

Certain facility types are exempt from POA reporting requirements (see Exhibit B listing exemptions such as Critical Access Hospitals, LTACs, inpatient psychiatric, rehabilitation, cancer hospitals, VA/DoD, etc.).

Coding, POA, and OPPC Diagnosis Codes

OPPC ICD-10 diagnosis codes and examplesICD-10Covered

Y65.51	Wrong surgery or invasive procedure on patient (ICD-10 diagnosis for wrong surgery)
Y65.52	Surgical or invasive procedure on the wrong patient (ICD-10 diagnosis)
Y65.53	Surgical or invasive procedure on the wrong body part (ICD-10 diagnosis)

POA reporting requirement

RequirementPOA indicator required for all inpatient primary and secondary diagnoses (POA not required on the admitting diagnosis)

ConsequenceFailure to include POA for primary/secondary diagnoses may result in claim denial or rejection

ScopePOA indicators must be submitted on inpatient facility claims as identified by CMS

ExemptionsCertain facility types may be exempt from POA reporting (see policy Exhibit B) — POA code '1' indicates exempt/not used

Provider Billing, Documentation, and Submission Requirements

Documentation Required

POA reporting and OPPC claim submission

Submit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses; POA is not required on the admitting diagnosis. For inpatient erroneous surgical events (OPPC), submit the inpatient event on a Type of Bill 0110 (no‑pay claim) and submit related services on separate claims. Failure to include required POA indicators may result in claim denial or rejection.

POA indicators required for all inpatient primary and secondary diagnoses; not required on admitting diagnosis.
If POA identifies an HCAC, related charges/days will be removed when calculating the DRG.
Inpatient OPPC events should be submitted on Type of Bill 0110 (no‑pay claim) with related services on separate claims.

Billing Rule

Member billing prohibition

Do not seek payment from the member for nonreimbursable services related to a Provider Preventable Condition; the member must be held harmless.

Neither the professional provider nor facility may bill the member for PPC-related nonreimbursable services.

Documentation Required

Clinical review and records request

Anthem may request additional medical records from the professional provider or facility and subject claims to clinical review to support documentation for reimbursement of a PPC.

Claims may be subject to clinical review for appropriate reimbursement consideration.
Providers must provide requested records to support the documentation submitted for PPC-related reimbursement.

Key Definitions

Provider Preventable Conditions (PPC)

DefinitionProvider Preventable Conditions (PPC): Conditions for which Anthem Medicare Advantage does not reimburse unless provider, state, federal, or CMS contracts require otherwise

IncludesHealth Care-Acquired Conditions (HCAC) and Other Provider Preventable Conditions (OPPC)

Member billingNeither the professional provider nor facility may seek payment from the member for nonreimbursable services related to a PPC; member must be held harmless

Clinical reviewAnthem may request additional records and subject claims to clinical review to determine appropriate reimbursement for PPCs

Health Care-Acquired Conditions (HCAC)

DefinitionHealth Care-Acquired Conditions (HCAC): Medical conditions or complications not present at admission that develop during a hospital stay (examples listed in Exhibit C)

DRG impactIf POA indicates HCAC (not present on admission), related charges/days are removed when calculating DRG reimbursement; non-DRG reimbursement may also be reduced

Reimbursement methodologyAnthem reimburses using the CMS MS-DRG algorithm and will adopt future CMS/state HCAC categories or grouper changes

Pre-existing conditionReimbursement will not be reduced or denied if a HCAC existed prior to the facility's initiation of treatment

Other Provider Preventable Conditions (OPPC)

DefinitionOther Provider Preventable Conditions (OPPC): Erroneous surgical events such as wrong body part, wrong patient, or wrong surgery/invasive procedure

Claim handlingProcedures identified as OPPC and all related services for professional providers and facilities will be rejected or denied

Inpatient OPPC submissionErroneous surgical events during an inpatient stay should be submitted on Type of Bill 0110 (no-pay claim) with related services on separate claims

CodingProviders should use appropriate codes to report OPPCs; Anthem may adopt CMS-recognized OPPC procedures

Present on Admission (POA)

POA indicator codesY = present at time of inpatient admission; N = not present at time of inpatient admission; U = documentation insufficient; W = clinically undetermined; 1 = Unreported/Not used (exempt)

PurposeUsed to report whether a diagnosis was present at time of inpatient admission on inpatient facility claims

EquivalenceCode '1' is equivalent to a blank on the UB-04 but denotes exempt from POA reporting for systems submitting via /00410A