CurrentEmpire BluecrossPolicy G-20003

Provider Preventable Conditions (PPC) — Reimbursement Policy

This reimbursement policy governs Anthem Medicare Advantage reimbursement for provider preventable conditions (PPCs), including Health Care-Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs), and describes billing, POA reporting, and reimbursement adjustments for applicable inpatient and professional claims affecting providers serving Anthem Medicare Advantage members. Applies to the listed Medicare Advantage states and facilities as noted.

Policy Summary

PayerEmpire Bluecross

PolicyProvider Preventable Conditions (PPC) — Reimbursement Policy

Policy CodePolicy G-20003

Change TypeClarified HCAC algorithm and retitled policy

Effective DateMar 22, 2023

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

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

POA requiredPOA reporting requirement

Held harmlessMember financial liability

Wrong surgery/patient/partOPPC categories

Provider Preventable Conditions Coverage

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PPC Coverage Criteria

Covered when ALL of the following conditions apply:

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

PPCs include Health Care‑Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs).

POA indicators are required for all inpatient primary and secondary diagnoses; omission may result in claim denial or rejection.

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

Anthem reimburses using the CMS MS‑DRG grouper; future HCAC categories or changes to the CMS grouper algorithm are deemed adopted by Anthem Medicare Advantage.

OPPCs are surgical or other invasive procedures erroneously performed (wrong body part, wrong patient, wrong surgery); procedures identified as OPPCs and all related services will be rejected or denied.

Erroneous inpatient surgical events should be submitted on Type of Bill 0110 (no‑pay claim) with all services related to the surgery on that claim; other inpatient services should be submitted on separate claims.

Providers may not seek payment from the member for nonreimbursable services related to a PPC (member held harmless).

Anthem may request additional records and perform clinical review for reimbursement consideration; incorrect use of the PC modifier may lead to denial and require corrected resubmission.

Examples / coding

ICD‑10 codes for OPPC events: 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).
Associated modifiers: PA = wrong body part; PB = wrong patient; PC = wrong surgery.

Exemptions

Certain Medicare‑exempt facilities are exempt from POA reporting requirements (e.g., LTACs, CAHs, inpatient psychiatric, inpatient rehabilitation, cancer hospitals, VA/DoD).

A condition defined as a HCAC or OPPC that existed prior to initiation of treatment by the reporting facility/provider will not reduce that provider's reimbursement on the basis of another provider's prior care.

Coding, POA & ICD-10 Guidance

OPPC ICD-10 codes and modifiersICD-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

POA applicability — Required for all inpatient primary and secondary diagnoses as identified by CMS

ApplicabilityPOA indicators are required for all inpatient primary and secondary diagnoses as identified by CMS.

Admitting diagnosisPOA indicator is not required on the admitting diagnosis.

Consequence of omissionFailure to include POA with primary and secondary diagnosis codes may result in claim denial or rejection.

Effect on DRG calculationIf POA identifies an HCAC, related charges/days are removed from the claim when calculating the DRG reimbursement.

Future updatesCategories or changes recognized by CMS or the state (including grouper algorithm updates) are deemed adopted by Anthem Medicare Advantage.

Billing, POA Reporting, and No-Pay Claim Requirements

Documentation Required

POA reporting and OPPC no-pay claim requirements

Submit Present on Admission (POA) indicators 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. For inpatient erroneous surgical events (OPPC), report the event using Type of Bill 0110 (no-pay claim) and submit related services on separate claims.

POA indicators are required for all inpatient primary and secondary diagnoses; POA is not required on the admitting diagnosis. (See Exhibit A for indicator definitions.)
If POA identifies an HCAC, related charges/days will be removed from the claim when calculating DRG reimbursement.
Use Type of Bill 0110 (no-pay claim) to report inpatient erroneous surgical events and submit related services on separate claims.

Key Definitions

HCAC — Health Care-Acquired Conditions (HCAC)

DefinitionHealth Care-Acquired Conditions (HCAC): Medical conditions or complications not present on admission that develop because of errors or accidents during the hospital stay.

IdentificationHCACs must be identified through submission of Present on Admission (POA) indicators on inpatient facility claims.

Reimbursement impactWhen POA identifies a HCAC, related charges/days are removed from DRG calculation; only CCs/MCCs identified as HCACs are excluded.

ScopeHCACs are adopted consistent with CMS definitions and future CMS/state-recognized categories are adopted by Anthem Medicare Advantage.

OPPC — Other Provider Preventable Conditions (OPPC)

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

Billing for inpatient erroneous eventsErroneous surgical events occurring during an inpatient stay should be reported on Type of Bill 0110 (no-pay claim) with all services/procedures related to the surgery; other inpatient services should be on separate claims.

Reimbursement handlingProcedures identified as OPPCs and all related services for professional providers and facilities will be rejected or denied.

AdoptionAnthem Medicare Advantage reserves the right to adopt procedures recognized by CMS as OPPCs.

POA indicator — Present on Admission (POA) indicators

YPresent at time of inpatient admission.

NNot present at time of inpatient admission.

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

WClinically undetermined — provider unable to clinically determine whether condition was present at time of inpatient admission.

Blank/ExemptUnreported/Not used — exempt from POA reporting (code equivalent of a blank on the UB-04).