CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and Reimbursement Policy: Coding Claim Submissions for Never Events and Hospital Acquired Conditions

Governance of coding, billing, and reporting requirements for 'Never Events' and Hospital-Acquired Conditions (HACs) for providers billing Neighborhood Health Plan of Rhode Island; affects hospitals, outpatient/ambulatory surgical centers, and practitioners submitting claims to the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoding Claim Submissions for Never Events and Hospital Acquired Conditions

Policy CodePolicy N/A

Change TypeNo material change

Effective Datedischarge dates after October 1, 2009; coding reqs enforced July 1, 2012

Next Review Date

Key ActionHospitals must submit two claims when a surgical error is reported: a no-pay TOB 110 for the non-covered erroneous procedure and a separate bill for covered services with matching Statement Covers Period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

July 1, 2012coding requirements enforcement

Oct 1, 2009required coding effective (discharge)

3/2012publication date

Billing & Payment Adjustments for Never Events and HACs

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Hospitals must submit two claims when a surgical error is reported: (1) a no-pay UB-04 TOB 110 for the non-covered erroneous procedure(s) and (2) a separate bill (TOB other than 110) for covered services/procedures unrelated to the erroneous surgery; both claims must have matching Statement Covers Period.

ALL of the following

The non-covered TOB 110 must report one of the following diagnosis codes in diagnosis positions 2–9: E876.5 (Performance of wrong operation on correct patient), E876.6 (Performance of operation on patient not scheduled for surgery), or E876.7 (Performance of correct operation on wrong side/body part).
The E876.x codes must not be reported in the External Cause of Injury (E-code) field.

For outpatient/ambulatory surgical center and practitioner claims, append the appropriate HCPCS modifier to all lines related to the erroneous surgery: PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient), or PC (Wrong Surgery on Patient).

ALL of the following

Hospitals must report the Present on Admission (POA) indicator for all inpatient ICD-9-CM diagnosis codes on the inpatient claim (UB-04 boxes 67A–67Q).
Payment impact if HAC/complication not POA
- If a listed complication or comorbidity is not present on admission and it is the sole reason that elevates the claim from a lower-reimbursed DRG to a higher-reimbursed DRG, reimbursement will be reduced to the lower-reimbursed DRG consistent with Medicare practice.
- For payments not based on DRG or for claims meeting hospital-acquired condition specifications, Neighborhood may reduce or partially retract payment consistent with Medicare practice.

Diagnosis, POA, and UB-04 Coding Requirements

Never event diagnosis codes and modifiersICD-10 | HCPCSCovered

E876.5	Performance of wrong operation (procedure) on correct patient
E876.6	Performance of operation (procedure) on patient not scheduled for surgery
E876.7	Performance of correct operation (procedure) on wrong side/body part
PA	HCPCS modifier: Surgery Wrong Body Part
PB	HCPCS modifier: Surgery Wrong Patient
PC	HCPCS modifier: Wrong Surgery on Patient

POA indicator requirement for inpatient claimsmixedCovered

No codes listed

Diagnosis code positions

RequirementE876.x diagnosis codes must be reported in diagnosis positions 2-9 on claims.

Applicable claim formsRequired for UB-04 inpatient claims and CMS-1500/CMS forms where applicable per summary grid.

Prohibited placementThese codes must not be reported in the External Cause of Injury (E-code) field.

UB-04 no-pay bill type for non-covered erroneous procedures

TOB for non-covered erroneous proceduresUse UB-04 Type of Bill (TOB) 110 for the no-pay claim reporting the non-covered erroneous procedure.

Paired billingTOB 110 no-pay claim must be submitted along with a separate bill for covered services; both claims must have matching Statement Covers Period.

Summary grid confirmationSummary grid lists UB-04 of bill type = 110 for never event no-pay claims.

Provider Billing Steps and POA Reporting

Billing Rule

Two-claim billing requirement for surgical errors

Hospitals must submit two claims when a surgical error is reported: a no-pay UB-04 of Bill Type (TOB) 110 for the non-covered erroneous procedure(s) and a separate claim (TOB other than 110) for covered services unrelated to the erroneous surgery. Both the covered and non-covered claims must have a matching Statement Covers Period.

Non-covered services/procedures related to the erroneous surgery must be billed on TOB 110 (no-pay).
Covered services unrelated to the erroneous surgery must be billed on a separate claim (TOB other than 110).
Statement Covers Period must match on both claims.

Billing Rule

Coding and modifier requirements for never events

The non-covered TOB 110 must report one of ICD-9-CM codes E876.5, E876.6, or E876.7 in diagnosis positions 2–9. For outpatient/ASC/practitioner claims, providers must append HCPCS modifiers PA, PB, or PC to all lines related to the erroneous surgery.

Acceptable ICD-9-CM codes for TOB 110 in diagnosis positions 2–9: E876.5, E876.6, E876.7.
Do not report these codes in the External Cause of Injury (E-code) field.
Append modifier PA, PB, or PC on CMS-1500 / outpatient/ASC/practitioner line items related to the erroneous surgery.

Documentation Required

POA reporting requirement

Hospitals must report the Present on Admission (POA) indicator on UB‑04 boxes 67A–67Q for all inpatient ICD-9-CM diagnosis codes submitted with the claim, effective July 1, 2012.

POA coding is required in Boxes 67A through 67Q (UB‑04) for inpatient claims.
Report a POA indicator for each reported inpatient diagnosis code.

Denial Risk

Payment reduction for HACs

If a listed complication or co-morbidity not present on admission is the sole reason a claim is elevated to a higher‑reimbursed DRG, reimbursement will be reduced to the lower‑reimbursed DRG consistent with Medicare practice; Neighborhood may reduce or partially retract payments for hospital‑acquired conditions.

When HACs cause DRG elevation but were not present on admission, payment will be adjusted down to the lower‑reimbursed DRG.
For non‑DRG payment methodologies, Neighborhood will reduce payments consistent with Medicare practice and may partially retract payments for HACs.

Key Terms

Never Events — definition

DefinitionNever Events: Serious reportable events (surgical errors) that must be reported to EOHHS and RI DOH; providers must self-report and follow specified coding and billing elements.

Required reportingNeighborhood Health Plan of Rhode Island is required by law to report all Never Events to the Executive Office of Health and Human Services (EOHHS) and the Rhode Island Department of Health (DOH).

Effective datesRequired coding elements effective for discharge dates after October 1, 2009; enforcement of coding requirements effective July 1, 2012.

POA — Present on Admission indicator

DefinitionPresent on Admission (POA) indicator: coding used to denote whether a diagnosis was present at the time of inpatient admission; required in UB-04 boxes 67A–67Q.

Mandatory reportingHospitals are required to report the POA indicator for all reported ICD-9-CM diagnosis codes on inpatient claims.

Payment impactIf a listed complication/co-morbidity not present on admission is the sole reason for DRG elevation, the hospital will be reimbursed only for the lower-reimbursed DRG (consistent with Medicare practice); Neighborhood may reduce or partially retract payment for HACs.