CurrentAnthemPolicy G-20003

Provider Preventable Conditions (PPC) — Reimbursement Policy

Defines Anthem Wisconsin BadgerCare Plus and Medicaid SSI reimbursement rules for Provider Preventable Conditions (including Health Care Acquired Conditions and Other Provider Preventable Conditions) and requirements for Present on Admission reporting that affect inpatient facility and professional claim reimbursement.

Policy Summary

PayerAnthem

PolicyProvider Preventable Conditions (PPC) — Reimbursement Policy

Policy CodePolicy G-20003

Change TypeNo material changes

Effective DateMar 22, 2023

Next Review DateN/A

Key ActionSubmit Present on Admission (POA) indicators for all inpatient primary and secondary diagnoses; missing POA 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 protection

14 categoriesHCAC categories

Exempt facility listPOA exemptions

03/22/2023Effective Date

Policy Summary

PayerAnthem

PolicyProvider Preventable Conditions (PPC) — Reimbursement Policy

Policy CodePolicy G-20003

Change TypeNo material changes

Effective DateMar 22, 2023

Next Review DateN/A

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

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PPC coverage criteria

Covered when ALL of the following are met:

POA indicator must be submitted 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.

If the POA indicator identifies a Health Care Acquired Condition (HCAC), related charges and/or days will be removed from the claim when calculating DRG reimbursement; only CCs or MCCs identified as HCACs are excluded from DRG assignment and non‑DRG reimbursement may also be reduced.

Reimbursement will not be reduced or denied if the HCAC existed prior to the facility’s initiation of treatment; if one facility caused the HCAC, payment will not be denied to a secondary treating facility.

Other Provider Preventable Conditions (OPPCs) — defined as wrong body part, wrong patient, or wrong surgery — and all related professional and facility services will be rejected or denied.

Erroneous surgical events that occur during an inpatient stay must be submitted on Type of Bill 0110 (nopay claim) with all services or procedures related to the surgery on that claim; all other inpatient procedures and services should be submitted on a separate claim.

Neither professional providers nor facilities may seek payment from the member for nonreimbursable services related to a PPC; the member must be held harmless.

Providers must use the appropriate ICD‑10 diagnosis codes (Y65.51, Y65.52, Y65.53) and modifiers (PA, PB, PC) for OPPC reporting; the PC modifier is defined as Wrong Surgery on a Patient and should not be used to represent the professional component — claims that incorrectly use PC may be denied.

Anthem may request additional records and may subject claims to clinical review to support reimbursement consideration for a PPC.

Anthem will adopt any future HCAC or OPPC categories/conditions recognized by CMS or the state, or changes to the grouper algorithm.

Provider Reporting, Billing and Documentation Requirements

Documentation Required

Health Care Acquired Conditions (HCAC) — POA Reporting

Anthem requires the identification of Health Care Acquired Conditions (HCACs) through submission of a Present on Admission (POA) indicator for all inpatient primary and secondary diagnosis codes as identified by CMS. POA indicators are required for all inpatient primary and secondary diagnoses; the POA indicator is not required on the admitting diagnosis. Failure to submit the POA indicator with the primary and secondary diagnosis codes may result in claim denial or rejection. If a POA indicator identifies a HCAC, charges and/or days related to that HCAC will be removed from the claim when calculating DRG reimbursement for inpatient services. Only CCs or MCCs identified as HCACs will be excluded when calculating the DRG; non‑DRG reimbursement may also be reduced. 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. Anthem will adopt future HCAC categories/conditions recognized by CMS or the state or changes to the grouper algorithm.

Submit POA indicator for all inpatient primary and secondary diagnoses (see Exhibit A).
POA indicator is not required on the admitting diagnosis.
Failure to include POA may result in claim denial or rejection.
Charges/days for POA-identified HCACs will be excluded when calculating DRG reimbursement.
Facility that caused the HCAC remains responsible; secondary facilities will not be denied payment for treatment of the HCAC.

Billing Rule

Other Provider Preventable Conditions (OPPC) — Billing & Claim Submission

Anthem identifies Other Provider Preventable Conditions (OPPC) as surgical or other invasive procedures (or services related to such procedures) that are erroneously performed. For professional providers and facilities, procedures identified as OPPCs and all related services will be rejected or denied. Erroneous surgical events occurring during an inpatient stay should be reported on a Type of Bill 0110 (no‑pay claim) including all services/procedures related to the erroneous surgery; all other inpatient procedures/services should be submitted on a separate claim. Providers should use the appropriate ICD‑10 and modifier codes when reporting OPPC events. Anthem may request additional records and clinical review for reimbursement consideration. Neither professional providers nor facilities may seek payment from the member for nonreimbursable services related to an OPPC — the member must be held harmless.

Use ICD‑10 Y65.x codes and the specific modifiers below to report OPPC events: Y65.51 = Wrong surgery or invasive procedure on patient; Y65.52 = Surgical/invasive procedure on wrong patient; Y65.53 = Surgical/invasive procedure on wrong body part.
Modifiers: PC = Wrong surgery on a patient; PB = Wrong patient; PA = Wrong body part. Do not use PC to indicate professional component.
Erroneous inpatient surgical events: submit as Type of Bill 0110 (no‑pay claim) with all related services/procedures; submit other inpatient procedures/services on separate claims.
Claims incorrectly using OPPC modifiers (e.g., PC used improperly) may be denied; denied claims may be resubmitted as corrected claims with appropriate coding.

Key Definitions

Provider Preventable Conditions (PPC) — definition and policy relation

DefinitionProvider Preventable Conditions (PPC) are conditions defined as Health Care Acquired Conditions (HCAC) or Other Provider Preventable Conditions (OPPC) that Anthem does not reimburse unless provider, state, federal, or CMS contracts require otherwise.

Scope of reimbursement ruleAnthem does not reimburse for PPCs unless contracts or requirements indicate otherwise; Anthem may adjust or deny reimbursement when PPCs are identified.

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

Documentation and review rightsAnthem reserves the right to request additional records and to subject claims to clinical review to support reimbursement consideration for a PPC.

Health Care Acquired Conditions (HCAC) — definition and scope

DefinitionHealth Care Acquired Conditions (HCAC) are medical conditions or complications not present at admission that develop during a hospital stay.

POA requirementHCACs must be identified through submission of a Present on Admission (POA) indicator for all inpatient primary and secondary diagnoses; failure to include POA may result in claim denial or rejection.

Effect on DRG and reimbursementIf the POA indicator identifies a HCAC, related charges/days are removed when calculating DRG reimbursement; CCs/MCCs identified as HCACs are excluded from DRG assignment and non‑DRG reimbursement may be reduced.

Preexisting and inter‑facility rulesReimbursement will not be reduced or denied if the HCAC existed prior to the facility's initiation of treatment; if one facility caused the HCAC, payment will not be denied to a secondary treating facility.

Other Provider Preventable Conditions (OPPC) — definition and examples

DefinitionOther Provider Preventable Conditions (OPPC) are surgical or other invasive procedures, or services related to a procedure, when a surgical procedure is erroneously performed (wrong patient, wrong body part, or wrong procedure).

Categorization examplesOPPC categories include: surgical/invasive procedure on the wrong body part; surgical/invasive procedure on the wrong patient; wrong surgery or invasive procedure on a patient.

Coding and billing instructionsProviders should use appropriate ICD‑10 Y65.x diagnosis codes and modifiers (PA, PB, PC); erroneous inpatient surgical events should be submitted on Type of Bill 0110 (nopay claim) with related services on separate claims.

Rejection/denial consequenceFor professional providers and facilities, procedures identified as OPPCs and all related services will be rejected or denied; a condition that existed prior to another provider's treatment will not impact that provider's reimbursement.

OpenPayer

Provider Preventable Conditions (PPC) — Reimbursement Policy

Reimbursement Rules for Provider Preventable Conditions (PPC)

Codes, Modifiers, and POA Indicators

Provider Reporting, Billing and Documentation Requirements

Key Definitions

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

PA	Modifier for surgical/invasive procedure on wrong body part
PB	Modifier for surgical/invasive procedure on wrong patient
PC	Modifier for wrong surgery on a patient (PC modifier should not be used to represent professional component)