Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment updates the list of Medicare
Hospital Acquired Conditions which are incorporated by
reference.
(1) Definitions.
(A) "Provider Preventable Conditions (PPC) "
is an umbrella term for hospital and non-hospital acquired conditions
identified by the state for nonpayment to ensure the high quality of Medicaid
services. PPCs include two (2) distinct categories, Health Care-Acquired
Conditions (HCAC) and Other Provider-Preventable Conditions (OPPC).
(B) "Health Care-Acquired Conditions (HCAC)"
means conditions that occurred during a Medicaid inpatient hospital stay. HCACs
are set forth in the most current list of Medicare Hospital Acquired
Conditions, with the exception of Deep Vein Thrombosis/Pulmonary Embolism
following total knee replacement or hip replacement in pediatric and obstetric
patients, as the minimum requirements for states' PPC nonpayment
program.
(C) "Other
Provider-Preventable Conditions (OPPC)" means conditions occurring in any
health care setting that include, at a minimum, wrong surgical or other
invasive procedure performed on a patient; surgical or other invasive procedure
performed on the wrong body part; surgical or other invasive procedure
performed on the wrong patient pursuant to
42 CFR
447.26(b).
(2) Payment to hospitals or
ambulatory surgical centers enrolled as MO HealthNet providers for care related
only to the treatment of the consequences of a HCAC will be denied or recovered
by the MO HealthNet Division when the HCAC is determined to have occurred
during an inpatient hospital stay and would otherwise result in an increase in
payment. HCAC conditions are identified in the list of Medicare Hospital
Acquired Conditions, which is incorporated by reference and made part of this
rule as published by the Centers for Medicare & Medicaid Services (CMS) at
their website at
https://www.cms.gov/medicare/payment/fee-for-service-providers/hospital-aquired-conditions-hac/icd-10,
August 3, 2023. This rule does not incorporate any subsequent amendments or
additions published by CMS after August 3, 2023.
(A) Hospitals or ambulatory surgical centers
enrolled as MO HealthNet providers shall include the "Present on Admission"
(POA) indicator on the CMS 1450 UB-04 or electronic equivalent when submitting
inpatient claims for payment. The POA indicator is to be used according to the
Official Coding Guidelines for Coding and Reporting and the Center for Medicare
and Medicaid Services (CMS) guidelines. The POA indicator prompts review of
inpatient hospital claims with a HCAC diagnosis code.
(B) All MO HealthNet enrolled hospitals or
ambulatory surgical centers must report HCACs on claims submitted to MO
HealthNet for consideration of payment.
(C) The MO HealthNet Division, or designee,
will identify the occurrence of HCACs based on the POA indicator and calculate
the payment recoupments based on the facts of each HCAC.
(3) Payment to hospitals or ambulatory
surgical centers enrolled as MO HealthNet providers for care related only to
the treatment of the consequences of an Other Provider-Preventable Condition
(OPPC) will be denied or recovered by the MO HealthNet Division when the OPPC
is determined to-
(A) Be within the control
of the hospital or ambulatory surgical center;
(B) Have occurred during an inpatient
hospital admission, outpatient hospital care, or care in an ambulatory surgical
center;
(C) Have resulted in
serious harm;
(D) Otherwise result
in an increase in payment of the identified OPPC; and
(E) Be a wrong surgical or other invasive
procedure performed on a patient; surgical or other invasive procedure
performed on the wrong body part; surgical or other invasive procedure
performed on the wrong patient.
(4) Other Provider-Preventable Conditions
(OPPC) are to be billed as follows:
(A)
Medical claims using the CMS 1500 claim form, must be billed with the surgical
procedure code and modifier which indicates the type of OPPC: modifier PA
(wrong body part), PB (wrong patient), or PC (wrong surgery), AND/OR at least
one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or
wrong body part must be present as one (1) of the first four (4) diagnosis
codes on the claim;
(B) Outpatient
hospital claims using the CMS 1450 UB-04 claim form or its electronic
equivalent must be billed with at least one (1) of the diagnosis codes
indicating wrong surgery, wrong patient, or wrong body part within the first
five (5) diagnosis codes listed on the claim;
(C) Inpatient hospital claims, using the CMS
1450 UB-04 claim form or its electronic equivalent must be billed with a type
of bill 0110.
1. If there are covered
services or procedures provided during the same stay as the OPPC, then the
facility must submit two (2) claims; one (1) claim with covered services
unrelated to the OPPC event and the other claim for any and all services
related to the OPPC event.
2. The
Type of Bill 0110 claim must also contain one (1) of the diagnosis codes
indicating wrong surgery, wrong patient, or wrong body part within the first
five (5) diagnosis codes listed on the claim; and
(D) The MO HealthNet Division will identify
the occurrence of OPPCs based on the type of bill, diagnoses, procedures, and
Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System
(HCPCS) modifiers submitted on the claim. Payment for the claims will be
denied, if appropriate.
(5) A MO HealthNet participant shall not be
liable for payment for an item or service related to an OPPC or HCAC or the
treatment of consequences of an OPPC or HCAC that would have been otherwise
payable by the MO HealthNet Division.
*Original authority: 208.153, RSMo 1967, amended 1967,
1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended
2007.
