CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Provider Preventable Conditions (PPC) non-payment policy

Governs Neighborhood Health Plan of Rhode Island's non-reimbursement approach for Provider Preventable Conditions (including Hospital Acquired Conditions and Other Provider Preventable Conditions) and the required billing/reporting for affected services across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyProvider Preventable Conditions (PPC) non-payment policy

Policy CodePolicy N/A

Change TypeFormat updateapplicability expansion (no material clinical changes)

Effective DateJul 1, 2012

Next Review DateN/A

Key ActionReport any PPC occurrence on claims and notify Neighborhood's Medical Management Department; submit complete claims within timely filing guidelines.

SourceLink

POLICY UPDATE CHANGES

Format changes on 10/01/2022 with no content changes.

01/06/2020 update to include all lines of business.

14 categoriesCMS-designated Hospital Acquired Condition categories

3 examplesminimum OPPC 'never events' listed

POA indicator setPOA reporting mandatory

National & local criteriaMedical necessity references

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Non‑Payment & Coverage Criteria for Provider Preventable Conditions

Non-payment criteria and billing rules

Neighborhood does not reimburse providers for services attributed to Provider Preventable Conditions (PPCs) that develop during a hospital stay or that meet the definition of Other Provider Preventable Conditions (OPPC/'never events'). Claims must be billed and coded according to the rules below to be identified as non-payable.

ALL of the following

ALL of the following
- ANY of the following
  - Hospital Acquired Condition (HAC) - condition not present on admission as identified in CMS HAC lists
  - Other Provider Preventable Condition (OPPC) / 'Never Event' - events such as wrong procedure, wrong body part, or wrong patient
ALL of the following
- The condition developed during a hospital stay or occurred as an OPPC regardless of place of service

ALL of the following

All services provided in the operating room or other healthcare setting when an OPPC or HAC occurs are considered related to the PPC and are not reimbursed
Any providers present who could bill individually are not eligible for payment for those services and must repost them as HAC-related services

ALL of the following

Any follow-up services provided as a result of a previously reported PPC involving the same member are not reimbursed and must be reported as HAC-related services

ALL of the following

Members assume no liability for HAC or HAC-related services deemed nonreimbursable, including copays or deductibles
Related services do not include the performance of the correct procedure

ALL of the following

Inpatient facility claims with HACs must include the Present on Admission (POA) indicator; POA values (Y/N/U/W/1) determine payment implications
Non-covered claims for OPPCs (Bill Type 0110) must contain one of the specified diagnosis codes (Y65.51, Y65.52, Y65.53) and the applicable HCPCS modifiers (PA, PB, PC) on related claim lines

ALL of the following

All services must meet medical necessity; Neighborhood may reference NCD/LCD/InterQual/EOHHS/CMP to determine necessity
Neighborhood may request medical records and claims are subject to audit per CMS documentation standards
Coding must comply with CPT, ICD-10-CM and HCPCS Level II standards and claims must be submitted within contractual timely filing guidelines

Exceptions / POA payment outcomes

Y = diagnosis present on admission; payment will be made for the condition
N = diagnosis not present on admission; applicable PPC payment adjustments will be made (non-payment)
U = documentation insufficient to determine POA; applicable PPC payment adjustments will be made
W = clinically undetermined; payment will be made for the condition
1 = unreported/not used (exempt from POA reporting)

ALL of the following

Providers must report occurrence of a PPC to Neighborhood via claims submission and notify Neighborhood's Medical Management Department as required; submit complete claims in accordance with timely filing and coding standards

ALL of the following

HACs are those categories designated by CMS (14 categories) and the complete ICD-10 code lists are published by CMS
OPPCs include at minimum wrong procedure, wrong body part, and wrong patient and are non-reimbursable regardless of place of service

ALL of the following

Policy applies to services performed on or after July 1, 2012, and applies across Neighborhood's lines of business as described in the policy

ALL of the following

All services that are related to the PPC must be reported as HAC-related services on claims submission; providers who could bill individually must repost such services accordingly

ALL of the following

Verify eligibility, coverage and authorization prior to rendering services; follow plan-specific prior authorization reference and clinical medical policies

ALL of the following

Claims are subject to audit and must adhere to contractual billing, coding and documentation requirements; Neighborhood follows federal requirements (Section 2702 of the ACA and 42 CFR 447.26)

ALL of the following

Diagnosis codes: Y65.51, Y65.52, Y65.53; HCPCS/Modifier codes: PA, PB, PC — must be appended to claim lines related to the incorrect surgery

ALL of the following

Complete ICD-10 HAC diagnosis code lists by federal fiscal year are available on the CMS website

ALL of the following

Services attributed to HACs or OPPCs are not reimbursed when not present on admission or when classified as 'never events'

ALL of the following

Policy effective date and revision history are maintained; providers should refer to the policy for format or applicability updates

ALL of the following

Append PA (Surgery Wrong Body Part), PB, or PC (Surgery Wrong Patient) modifiers to all claim lines related to the incorrect surgery as instructed

ALL of the following

Performance of the correct procedure is not considered a related service and may be paid if otherwise reimbursable

ALL of the following

Neighborhood may use national and local coverage determinations and clinical criteria (NCD, LCD, InterQual, EOHHS, CMP) to determine payment and medical necessity

ALL of the following

POA reporting is mandatory for all inpatient admissions to general acute care hospitals or other facilities

ALL of the following

A non-covered claim with Bill Type 0110 must include one of the OPPC diagnosis codes and applicable HCPCS modifiers

ALL of the following

Neighborhood will not reimburse increases in incremental costs of inpatient care or professional services resulting from HACs or OPPCs identified on CMS lists

ALL of the following

Coding must meet CPT, ICD-10-CM and HCPCS Level II standards for claim submission

ALL of the following

Providers must submit complete claims within contractually determined timely filing guidelines

ALL of the following

Examples of HAC categories include retained foreign object, air embolism, blood incompatibility, pressure ulcers, falls/trauma, catheter-associated infections, surgical site infections, DVT/PE after certain procedures, iatrogenic pneumothorax

ALL of the following

Neighborhood follows Section 2702 of the ACA and 42 CFR 447.26 prohibiting payment for provider preventable conditions

ALL of the following

POA code '1' indicates unreported/not used and is equivalent to a blank on the UB-04 (exempt from POA reporting)

ALL of the following

At minimum, OPPC/never events include wrong surgical procedure, wrong body part, and wrong patient

ALL of the following

To effect non-payment, providers must correctly code HAC/OPPC diagnoses, include POA indicators on inpatient claims, append required modifiers for wrong surgery claims, repost related services as HAC-related, and comply with documentation and timely filing requirements

Interaction with member cost-sharing

Key Definitions

Hospital Acquired Condition (HAC)

DefinitionAn undesirable condition or complication developed by a patient during a stay in a hospital or medical facility.

ClassificationHACs are one category of Provider Preventable Conditions (PPCs) and are identified on inpatient facility claims for payment determination.

Payment relevanceHAC diagnosis in combination with POA indicator controls whether payment or PPC adjustments apply.

Present on Admission (POA)

Definition (POA concept)Present on Admission (POA) denotes conditions present at the time an order for inpatient admission occurs, or conditions that develop during an outpatient encounter (including ED, observation, or outpatient surgery).

Inpatient vs Outpatient implicationPOA reporting is mandatory for inpatient admissions and the POA indicator combined with HAC diagnosis codes determines payment; outpatient encounters note presence but POA reporting requirement applies to inpatient facility claims.

Documentation standardPOA values (Y/N/U/W/1) reflect clinical documentation and drive payment or PPC adjustments.

Never Events

DefinitionNever Events (Other Provider Preventable Conditions) are adverse medical events that are clearly identifiable, measurable, serious enough to result in death or significant disability, and usually preventable.

ExamplesExamples include wrong procedure/operation on correct patient, operation on patient not scheduled for surgery, and correct operation on wrong side/body part (see OPPC diagnosis codes and modifiers).

Payment impactServices attributed to Never Events/OPPCs are not covered; claims must follow specified non-covered claim requirements and may require specific diagnosis codes and HCPCS modifiers.

HCPCS

DefinitionHealthcare Common Procedure Coding System (HCPCS) is a collection of standardized codes, developed by CMS, to represent procedures, supplies, products, and services provided in the delivery of healthcare.

Use in policyHCPCS Level II codes and specified modifiers are required on claims for certain OPPC/never event scenarios (e.g., wrong body part or wrong patient modifiers).

Coding standardsClaims must meet CPT, ICD-10-CM and HCPCS Level II standards for submission and adjudication.

OpenPayer

Provider Preventable Conditions (PPC) non-payment policy

Non‑Payment & Coverage Criteria for Provider Preventable Conditions

Diagnosis, Modifier and POA Coding Requirements

Provider Reporting, Claims Submission and Authorization Responsibilities

Key Definitions

Y65.51	Performance of wrong procedure (operation) on correct patient
Y65.52	Performance of operation (procedure) on patient not scheduled for surgery
Y65.53	Performance of correct operation (procedure) on wrong side/body part
PA	Modifier: Surgery Wrong Body Part
PB	Modifier: PB
PC	Modifier: Surgery Wrong Patient