CurrentAnthemPolicy C-23002

Provider Preventable Conditions - Professional and Facility

Defines Anthem's reimbursement policy not to reimburse for provider preventable conditions (hospital-acquired conditions and major surgical 'never events') for commercial lines, and describes billing, POA reporting, and denial/reduction rules for facilities and professional providers.

Policy Summary

PayerAnthem

PolicyProvider Preventable Conditions - Professional and Facility

Policy CodePolicy C-23002

Change TypeAdministrative consolidation

Effective Date09/01/2023

Next Review Date

Key ActionInclude POA indicators for all inpatient primary and secondary diagnoses on UB-04 claims to avoid denial or rejection; if a HAC is identified, related charges/days may be removed from DRG calculation and reimbursement may be reduced or denied.

SourceLink

POLICY UPDATE CHANGES

Created a blended policy for professional and facility by retiring the prior facility-only Preventable Adverse Events policy (C-10002) and adapting language into the new policy C-23002.

C-23002Policy number

09/01/2023Effective date

HAC & Never EventsPrimary PPC categories

POA requiredPOA indicator requirement for inpatient claims

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When Reimbursement May Be Reduced or Denied

When reimbursement may be reduced or denied for inpatient facility claims

Anthem will identify HACs via POA indicators and exclude HAC-related CC/MCC when calculating DRG or may reduce/deny non-DRG reimbursement. Reimbursement exceptions apply when condition was present prior to treatment or when another facility caused the HAC.

ALL of the following

Claim is an inpatient facility claim billed on a UB-04
All primary and secondary diagnoses must include a Present on Admission (POA) indicator
If a diagnosis is identified as a Hospital Acquired Condition (HAC) via POA, the HAC-related charge/days will be removed from DRG calculation and reimbursement may be reduced or denied
If the condition defined as HAC existed prior to initiation of treatment by that facility, reimbursement will not be reduced or denied
If one facility caused the HAC (primary), payment will not be denied to a secondary facility that treated the HAC

Major Surgical Never Events - Professional and Facility

Procedures classified as Never Events and all related services will be rejected or denied.

ANY of the following

Surgical or invasive procedure on the wrong body part
Surgical or invasive procedure on the wrong patient
Wrong surgery or invasive procedure on patient
Retention of a foreign object in a patient after surgery or other procedure

Relevant Codes and Status

Modifiers for Never EventsModifierNot Covered

PA	Modifier - Surgical or invasive procedure on the wrong body part
PB	Modifier - Surgical or invasive procedure on the wrong patient
PC	Modifier - Wrong surgery or invasive procedure on patient; also defined in policy as 'Wrong Surgery on a Patient'

ICD-10 Diagnosis Codes related to Never EventsICD-10Not Covered

Y65.53	Surgical or invasive procedure on the wrong body part
Y65.52	Surgical or invasive procedure on the wrong patient
Y65.51	Wrong surgery or invasive procedure on patient

Billing, Documentation, and Denial Risks

Documentation Required

Present on Admission (POA) reporting

POA indicators are required for all inpatient primary and secondary diagnoses on UB-04 claims. Failure to include POA may result in claim denial or rejection. POA is not required on the admitting diagnosis.

Billing Rule

Claims adjustments for HACs

If POA identifies a HAC, related charges/days will be removed from DRG calculation; non-DRG reimbursement may also be reduced. Anthem may adopt future CMS HAC categories and grouper changes.

Policy Scope and Clinical Context

Defines Anthem's reimbursement policy not to reimburse for Provider Preventable Conditions (PPC) — which include Hospital Acquired Conditions (HAC) and Major Surgical Never Events — for commercial lines. This policy applies to both facilities and professional providers and describes POA reporting requirements, billing and claims adjustment rules, and circumstances in which reimbursement may be reduced, denied, or rejected. The policy was initially approved 03/22/2023 and is effective 09/01/2023; it consolidates and replaces the prior facility-only Preventable Adverse Events policy into a blended professional and facility policy.

Exhibit B lists selected Hospital Acquired Condition categories that Anthem identifies for POA-based review and potential reimbursement adjustment. Selected items include: Foreign object retained after surgery; Air embolism; Blood incompatibility; Stage III and IV pressure ulcers; Falls and trauma (all injuries related to falls and trauma); Manifestations of poor glycemic control (including diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis or hyperosmolarity); Catheter-associated urinary tract infection (UTI); Vascular catheter-associated infection; Surgical site infection, mediastinitis, following CABG; Surgical site infection following bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery); Surgical site infection following certain orthopedic procedures (spine, neck, shoulder, elbow); Surgical site infection following cardiac implantable electronic device (CIED); Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee or hip replacement; and Iatrogenic pneumothorax with venous catheterization.

Key Terms

Key definitions

Provider Preventable Conditions (PPC)Conditions that Anthem does not reimburse for because they are considered preventable; includes Hospital Acquired Conditions (HAC) and Major Surgical Never Events.

Hospital Acquired Condition (HAC)Medical conditions or complications that were not present on admission but develop as a result of an error or accident during the hospital stay.

Major Surgical 'Never Events' (OPPC)Procedures identified as surgical or other invasive procedures erroneously performed (wrong patient, wrong body part, wrong procedure, or retention of a foreign object); these procedures and related services will be rejected or denied.

Present on Admission (POA) IndicatorIndicator used on inpatient claims to denote whether a diagnosis was present at the time of inpatient admission. Values include Y (present), N (not present), U (insufficient documentation), W (clinically undetermined), and legacy code 1 (not valid under 5010).

Exhibit A describes the required Present on Admission (POA) indicator values used on inpatient UB-04 claims. Values and meanings include: Y = Diagnosis was present at time of inpatient admission; N = Diagnosis was not present at time of inpatient admission; U = Documentation is insufficient to determine if condition was present at admission; W = Clinically undetermined (provider unable to determine whether condition was present at admission). The exhibit also notes the legacy code 1 (equivalent to a blank on the UB-04) is no longer valid under the 5010 format and exempt codes will have the POA field left blank.

Policy Update Changes

03/22/2023Initial approval (administrative consolidation)Latest

Initial approval 03/22/2023; retired Preventable Adverse Events - Facility (C-10002) and created blended policy C-23002 for professional and facility — administrative consolidation rather than a clinical criteria change.

09/01/2023Effective date (administrative)

Policy became effective 09/01/2023; administrative consolidation of prior facility-only policy into new blended professional and facility policy.