CurrentBlue Cross Blue Shield - NevadaPolicy C-23002

Provider Preventable Conditions (Professional and Facility)

Defines the Health Plan's reimbursement stance for provider preventable conditions (PPC), including hospital-acquired conditions and major surgical never events, and explains billing, documentation, and member-hold-harmless requirements for commercial providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProvider Preventable Conditions (Professional and Facility)

Policy CodePolicy C-23002

Change TypeNo material change

Effective DateSep 1, 2023

Next Review Date

Key ActionDo not bill members for services related to non-reimbursable provider preventable conditions; provide requested records for clinical review when asked.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POA requiredPOA requirement

Professional & facilityPolicy scope

DeniedNever events

Held harmlessMember protection

29HAC entries

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Reimbursement Stance for Provider Preventable Conditions

Coverage criteria for Provider Preventable Conditions

Covered when ALL of the following apply:

The Health Plan generally does not reimburse for Provider Preventable Conditions (PPC) unless provider, state, or federal contracts or mandates require otherwise.

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

If the 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.

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

The Health Plan may request additional records and perform clinical review to support reimbursement determinations for PPCs.

Providers must not bill members for non-reimbursable services related to a PPC; members are held harmless.

The Health Plan will adopt future CMS-recognized HACs or Never Events and changes to grouper algorithms as applicable.

Claims that incorrectly use modifiers (e.g., the PC modifier) may be denied and must be resubmitted with corrected coding.

Exhibit B - Hospital Acquired Condition Categories

Exhibit B enumerates conditions considered hospital-acquired/provider-preventable and relevant to reimbursement adjustments.

Air embolism

Foreign object retained after surgery

Blood incompatibility

Falls and trauma (includes all injuries related to falls and trauma)

Stage III and IV pressure ulcers

Manifestations of poor glycemic control (including Nonketotic Hyperosmolar Coma, Diabetic Ketoacidosis, Hypoglycemic Coma, Secondary Diabetes with Hyperosmolarity, Secondary Diabetes with Ketoacidosis)

Coding, POA, and HAC Code Lists

Example ICD-10 codes and modifiers for Never EventsICD-10

Y65.53	Surgical or invasive procedure on wrong body part (ICD-10 example listed)
Y65.52	Surgical or invasive procedure on wrong body part (alternate listing)
Y65.51	Wrong surgery or invasive procedure on patient

Hospital Acquired Condition list (Exhibit B)mixed

1	Air embolism
2	Foreign object retained after surgery
3	Blood incompatibility
4	Falls and trauma (includes all injuries related to falls and trauma)
5	Stage III and IV pressure ulcers
6	Manifestations of poor glycemic control
7	Nonketotic Hyperosmolar Coma
8	Diabetic Ketoacidosis
9	Hypoglycemic Coma
10	Secondary Diabetes with Hyperosmolarity

1–10 of 29

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POA reporting — UB-04 requirement

RequirementPOA indicator is required for all inpatient primary and secondary diagnoses on UB-04; omission may result in claim denial or rejection.

ScopePOA indicator is not required on the admitting diagnosis.

Effect on DRGIf POA identifies a HAC, related charges/days are removed when calculating DRG reimbursement; non-DRG reimbursement may also be reduced.

Multiple CC/MCCOnly CCs or MCCs identified as HACs will be excluded when calculating the DRG; other CCs/MCCs may result in a higher-paying DRG.

AdoptionFuture CMS-recognized HACs and changes to the grouper algorithm are adopted by the Health Plan.

Documentation, Billing, and Operational Requirements

Documentation Required

Documentation and Member Billing — Records May Be Requested

The Health Plan may request additional clinical records from the professional provider or facility to support documentation submitted for reimbursement. Claims related to provider-preventable conditions may be subject to clinical review to determine appropriate reimbursement.

The member must be held harmless — neither the professional provider nor facility may seek payment from the member for non-reimbursable services related to a provider-preventable condition.
Claims may be subject to clinical review; the Health Plan may request additional records to support documentation.

Denial Risk

Denial/Reduction Risk for HACs and Major Surgical Never Events

If the Present on Admission (POA) indicator on an inpatient claim identifies a Hospital Acquired Condition (HAC) or if a Major Surgical Never Event is identified, reimbursement for the episode of care may be reduced or denied. For Never Events (e.g., wrong-site, wrong-patient, wrong-procedure), professional and facility procedures and all related services will be rejected or denied.

Key Terms and Definitions

Provider Preventable Conditions (PPC) — definition

DefinitionProvider Preventable Conditions (PPC) are conditions for which the Health Plan does not reimburse unless contracts or mandates require otherwise.

IncludesHospital Acquired Conditions (HAC) and Major Surgical Never Events.

Reimbursement stanceProcedures identified as Never Events and all related services will be rejected or denied for professional providers and facilities.

Operational impactHealth Plan may request additional records and perform clinical review to support reimbursement considerations for PPCs.

POA indicator — Present on Admission codes and usage

Y - YesDiagnosis was present at time of inpatient admission.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProvider Preventable Conditions (Professional and Facility)

Policy CodePolicy C-23002

Change TypeNo material change

Effective DateSep 1, 2023

Next Review Date

Key ActionDo not bill members for services related to non-reimbursable provider preventable conditions; provide requested records for clinical review when asked.

SourceLink

On This Page

Catheter-associated urinary tract infection (CAUTI)

Surgical site infection: mediastinitis following coronary artery bypass graft (CABG)

Vascular catheter-associated infection

Surgical site infection following bariatric surgery for obesity (including gastroenterostomy, laparoscopic gastric bypass, laparoscopic gastric restrictive surgery)

Surgical site infection following certain orthopedic procedures (including spine, neck, shoulder, elbow, total knee replacement, hip replacement)

Surgical site infection following cardiac implantable electronic device (CIED)

Deep vein thrombosis (DVT) and pulmonary embolism (PE)

Iatrogenic pneumothorax with venous catheterization

POA indicators are required for all inpatient primary and secondary diagnoses on UB-04 claims; failure to include POA may result in denial or rejection.
When a HAC is identified, the related charges/days will be removed when calculating DRG reimbursement; only CCs/MCCs identified as HACs are excluded from DRG calculation.
Non-DRG reimbursement may also be reduced because of a HAC.
If a condition defined as a HAC existed prior to the facility’s initiation of treatment, reimbursement will not be reduced or denied.
If a HAC is caused by a primary facility, payment will not be denied to a secondary facility that treated the HAC.

Note

Policy Applicability and Updates

This policy is subject to applicable federal and state laws and the terms of the member's benefits at the time of service. The Health Plan reserves the right to review and update reimbursement policies periodically.

Policy updates, future CMS-recognized HACs, and changes to the grouper algorithm are adopted by the Health Plan as applicable.

N - NoDiagnosis was not present at time of inpatient admission.

U - UnknownDocumentation is insufficient to determine if condition was present at time of inpatient admission.

W - Clinically undeterminedProvider unable to clinically determine whether the condition was present at time of inpatient admission.

Blank / ExemptEquivalent of a blank on the UB-04 for codes exempt from POA reporting; POA field left blank for exempt codes.

Never Events — Major Surgical Never Events

DefinitionMajor Surgical Never Events are surgical or invasive procedures performed on the wrong patient, wrong body part, wrong surgery, or retention of a foreign object after a procedure.

ConsequenceFor professional providers and facilities, procedures identified as Never Events and all related services will be rejected or denied.

Adoption of CMS listHealth Plan reserves the right to adopt any procedures recognized by CMS as Never Events.

Hospital Acquired Conditions — Exhibit B categories

ReferenceExhibit B enumerates Hospital Acquired Condition categories (e.g., air embolism; foreign object retained after surgery; blood incompatibility; falls and trauma; Stage III/IV pressure ulcers; catheter-associated UTI; surgical site infections; DVT/PE; iatrogenic pneumothorax; vascular catheter-associated infection; manifestations of poor glycemic control; etc.).

CountExhibit B lists multiple HAC categories and subitems relevant to reimbursement adjustments.

UseConditions listed in Exhibit B are treated as HACs for POA determination and potential reimbursement impact.

Use of Reimbursement Policy / Legal Notice

Reproduction restrictionNo part of this publication may be reproduced, stored, or transmitted in any form or by any means without permission from Anthem Blue Cross and Blue Shield.

Legal attributionAnthem Blue Cross and Blue Shield is the trade name of multiple legal entities across states (see policy for state-specific attribution).

Policy updatesThis policy is subject to federal and state laws and the terms of a member's benefits; the Health Plan reserves the right to review and update policies periodically.