CurrentBlue Cross Blue Shield - MainePolicy C-23002

Provider Preventable Conditions - Professional and Facility

Defines the Health Plan's reimbursement stance for provider preventable conditions (hospital-acquired conditions and major surgical 'never events') for professional providers and facilities; applies to commercial claims submitted to the plan except where contracts or state/federal mandates indicate otherwise.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProvider Preventable Conditions - Professional and Facility

Policy CodePolicy C-23002

Change TypeNo material clinical or coverage changes in this revision

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionSubmit Present on Admission (POA) indicator for all inpatient primary and secondary diagnoses on the UB-04 to avoid claim denial or rejection.

SourceLink

2primary PPC categories

POA requiredPOA requirement

Member held harmlessMember billing protection

Claims may be denied/rejectedNever Events outcome

14+HAC categories listed

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Coverage and Reimbursement Rules

Coverage rules for Provider Preventable Conditions

Reimbursement consequences when a Provider Preventable Condition (PPC) is identified.

If the Present on Admission (POA) indicator on an inpatient UB-04 identifies a Hospital-Acquired Condition (HAC), charges and/or days related to the HAC shall be removed from the claim when calculating DRG reimbursement for inpatient hospital services; non-DRG based reimbursement may also be reduced.

Reimbursement will not be reduced or denied if the HAC existed prior to the initiation of treatment by that facility.

If a HAC is caused by one facility (primary), payment will not be denied to a secondary facility that treated the HAC.

Procedures identified as Major Surgical 'Never Events' and all related services for professional providers and facilities will be rejected or denied.

Neither the professional provider nor facility may seek payment from the member for non-reimbursable services related to a PPC; the member must be held harmless.

The Health Plan may request additional records from the professional provider or facility to support documentation submitted for reimbursement of a PPC; claims may be subject to clinical review.

The PC modifier is defined as 'Wrong Surgery on a Patient' and should not be used to represent the Professional Component; incorrect use may result in denial and claims must be resubmitted as corrected claims with appropriate coding.

Any future categories and/or conditions recognized by CMS as a HAC or changes to the grouper algorithm shall be deemed adopted by the Health Plan.

Provider Preventable Conditions - Coverage Stance

The policy enumerates specific hospital-acquired condition categories; reimbursement and claim handling are subject to federal and state laws and the member's benefit terms.

Listed HAC categories: The following Hospital-Acquired Condition (HAC) categories are tracked and may impact reimbursement or coverage decisions: 1) Foreign object retained after surgery; 2) Air embolism; 3) Blood incompatibility; 4) Stage III and IV pressure ulcers; 5) Falls and trauma (includes all injuries related to falls and trauma); 6) Manifestations of poor glycemic control (a. Diabetic Ketoacidosis; b. Nonketotic Hyperosmolar Coma; c. Hypoglycemic Coma; d. Secondary Diabetes with Ketoacidosis; e. Secondary Diabetes with Hyperosmolarity); 7) Catheter-associated urinary tract infection (UTI); 8) Vascular catheter-associated infection; 9) Surgical site infection, mediastinitis, following CABG; 10) Surgical site infection following bariatric surgery for obesity (a. Laparoscopic Gastric Bypass; b. Gastroenterostomy; c. Laparoscopic Gastric Restrictive Surgery); 11) Surgical site infection following certain orthopedic procedures (a. Spine; b. Neck; c. Shoulder; d. Elbow); 12) Surgical site infection following cardiac implantable electronic device (CIED); 13) Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee or hip replacement; 14) Iatrogenic pneumothorax with venous catheterization.

POA indicators are required for all inpatient primary and secondary diagnoses on the UB-04; failure to include POA for primary and secondary diagnoses may result in claim denial or rejection.

Use of this reimbursement policy is subject to federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service; the Health Plan may review and update these policies periodically.

Coding, Modifiers, and POA Indicators

ICD-10 codes for 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

Procedure modifiers for Never EventsModifierNot Covered

PA	Modifier for surgical or invasive procedure on the wrong body part
PB	Modifier for surgical or invasive procedure on the wrong patient
PC	Modifier for wrong surgery or invasive procedure on patient

Present on Admission (POA) indicatorsmixed

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 time of inpatient admission.
W	Clinically undetermined; provider unable to clinically determine whether condition was present at time of inpatient admission.
1	Equivalent of a blank on the UB-04; no longer valid on version 5010 claims effective January 1, 2011; POA field left blank for codes exempt from POA reporting.

Hospital-acquired condition categories (HACs)mixedNot Covered

	Foreign object retained after surgery
	Air embolism
	Blood incompatibility
	Stage III and IV pressure ulcers
	Falls and trauma (includes all injuries related to falls and trauma)
	Manifestations of poor glycemic control: Diabetic Ketoacidosis
	Manifestations of poor glycemic control: Nonketotic Hyperosmolar Coma
	Manifestations of poor glycemic control: Hypoglycemic Coma
	Manifestations of poor glycemic control: Secondary Diabetes with Ketoacidosis
	Manifestations of poor glycemic control: Secondary Diabetes with Hyperosmolarity

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Provider Billing, Documentation, and Claim Handling

Documentation Required

Submit POA for inpatient diagnoses

The Health Plan requires submission of a Present on Admission (POA) indicator for all inpatient primary and secondary diagnoses on UB-04 claims. Failure to include the POA indicator may result in the claim being denied or rejected. If a POA indicator identifies a Hospital Acquired Condition (HAC), charges and/or days related to that HAC will be removed from the claim when calculating DRG reimbursement; non‑DRG reimbursement may also be reduced. Reimbursement will not be reduced or denied if the HAC existed prior to initiation of treatment by that facility, and payment will not be denied to a secondary facility when a HAC was caused by a primary facility. The Health Plan adopts future CMS-recognized HAC categories and grouper changes.

POA indicator required for all inpatient primary and secondary diagnoses on UB-04
POA indicator not required on the admitting diagnosis
HAC-identified CCs/MCCs excluded from DRG calculation; may change DRG assignment or reduce non-DRG reimbursement
Past-existing conditions and secondary facility treatment are exceptions

Billing Rule

Member billing and records request

Neither professional providers nor facilities may seek payment from the member for non-reimbursable Provider Preventable Conditions (PPCs) or Never Event–related services. Members must be held harmless. The Health Plan may request additional records for clinical review to support reimbursement determination.

Do not bill members for non-reimbursable PPC/Never Event services
Health Plan may request additional records for review and appropriate reimbursement consideration

Denial Risk

Never Events denial policy

Procedures identified as "Never Events" (as defined below) and all related professional and facility services will be rejected or denied. Coding guidance: the PC modifier denotes 'Wrong Surgery on a Patient' and must not be used to indicate Professional Component; incorrect use may result in denial and require corrected claim resubmission with proper coding.

Never Events and related services will be denied/rejected
Incorrect use of the PC modifier may result in denial; resubmit as a corrected claim with appropriate coding

Note

Policy Use and Updates

This reimbursement policy is subject to applicable federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service. The Health Plan reserves the right to review and update these policies periodically. No part of this publication may be reproduced without permission from Anthem Blue Cross and Blue Shield.

Policy subject to federal/state laws and member benefit terms
Payer reserves right to review and update policies periodically
Reproduction restrictions apply

Key Definitions and POA Indicator Meanings

Hospital Acquired Conditions (HAC) — definition and brief explanation

DefinitionMedical conditions or complications not present at hospital admission that develop during a hospital stay as a result of an error or accident.

ScopeHACs are one of the two primary Provider Preventable Condition categories tracked by the plan (the other is Major Surgical 'Never Events').

Reimbursement impactWhen a HAC is identified via POA reporting, charges/days related to the HAC may be removed when calculating DRG reimbursement and non-DRG payments may be reduced.

Major Surgical 'Never Events' — definition (wrong patient/body part/surgery, retained foreign body, etc.)

DefinitionMajor Surgical 'Never Events' (Other Provider Preventable Conditions): procedures erroneously performed including surgery on the wrong patient, wrong body part, wrong surgery, or retention of a foreign object after a procedure.

ExamplesSurgery performed on the wrong patient; surgery performed on the wrong body part; wrong surgery performed on a patient; retention of a foreign object after surgery.

Payment stanceProcedures identified as Never Events and related services for professional providers and facilities will be rejected or denied; providers may not bill the member for these services.

POA indicator Y — Y = Diagnosis was present at time of inpatient admission

CodeY

MeaningDiagnosis was present at time of inpatient admission.

Usage noteUsed on UB-04 for inpatient primary and secondary diagnoses to indicate presence on admission.

POA indicator N — N = Diagnosis was not present at time of inpatient admission

CodeN

MeaningDiagnosis was not present at time of inpatient admission.

Reimbursement implicationAn N may identify a hospital-acquired condition that could impact DRG or other payments per policy rules.

POA indicator U — U = Documentation is insufficient to determine if condition was present at time of inpatient admission

CodeU

MeaningDocumentation is insufficient to determine if condition was present at time of inpatient admission.

ActionAdditional clinical documentation may be requested to clarify POA status.

POA indicator W — W = Clinically undetermined whether condition was present at time of inpatient admission

CodeW

MeaningClinically undetermined; provider unable to clinically determine whether the condition was present at the time of inpatient admission.

ImplicationUse indicates clinical uncertainty; payer may require further documentation or follow CMS guidance when determining reimbursement impact.