Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-550 - Hospital services
Section 182-550-1650 - Adverse events, hospital-acquired conditions, and present on admission indicators
Universal Citation: WA Admin Code 182-550-1650
Current through Register Vol. 24-06, March 15, 2024
(1) The rules in this section apply to:
(a) Inpatient
hospital claims with dates of admission on and after January 1, 2010;
(b) Payment or denial of payment for any
inpatient hospital claims identified in (a) of this subsection, including
medicaid supplemental or enhanced payments and medicaid disproportionate share
hospital (DSH) payments or denial of payment;
(c) Adverse events, hospital-acquired
conditions (HACs), and present on admission (POA) indicators (defined in
subsection (2) of this section);
(d) Hospital requirements to report adverse
events and HACs to the department (see subsection (4)(a) of this
section);
(e) Hospital requests for
retrospective utilization reviews and the related requirements to provide root
cause analysis of events to the department (see subsection (4)(d) through (f)
of this section); and
(f) Hospital
requirements to use POA indicator codes on claims (see subsection (5)(a) of
this section).
(2) The following definitions apply to this section:
(a)
"Adverse events" (also known
as "adverse health events" or "never events") are the events that must be
reported to the department of health (DOH) under WAC
246-320-146. These serious
reportable events are clearly identifiable, preventable, and serious in their
consequences for patients, and frequently their occurrence is influenced by the
policies and procedures of the health care organization.
(b)
"Hospital-acquired condition
(HAC)" is a condition that is reasonably preventable and was not present
or identifiable at hospital admission but is either present at discharge or
documented after admission. For medicaid payment purposes, the department
considers a HAC to be a condition that:
(i)
Is high cost or high volume, or both;
(ii) Results in the assignment of a case to a
diagnosis related group (DRG) that has a higher payment when present as a
secondary diagnosis;
(iii) Could
reasonably have been prevented through the application of evidence-based
guidelines; and
(iv) Does not
conflict with medicare's hospital-acquired conditions policy (http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage).
(c)
"Serious
disability" means a physical or mental impairment that substantially
limits the major life activities of a patient.
(d)
"Present on admission (POA)
indicator" is a status code the hospital uses on an inpatient hospital
claim that indicates if a condition was present or incubating at the time the
order for inpatient admission occurs. A POA indicator can also identify a
condition that develops during an outpatient encounter. (Outpatient encounters
include, but are not limited to, emergency department visits, diagnosis
testing, observation, and outpatient surgery.)
(e)
"Root cause analysis" is a
class of problem-solving methods aimed at identifying the root causes of events
instead of addressing the immediate, obvious symptoms.
(3) Medicare crossover inpatient hospital claims. The department applies the following rules for these claims:
(a) If medicare denies payment for a
claim at a higher rate for the increased costs of care under its HAC and/or POA
indicator policies:
(i) The department limits
payment to the maximum allowed by medicare;
(ii) The department does not pay for care
considered nonallowable by medicare; and
(iii) The client cannot be held liable for
payment.
(b) If medicare
denies payment for a claim under its National Coverage Determination authority
from Section 1862(a)(1)(A) of the Social Security Act (
42 U.S.C.
1395 ) for an adverse health event:
(i) The department does not pay the claim,
any medicare deductible, and/or any co-insurance related to the inpatient
hospital services; and
(ii) The
client cannot be held liable for payment.
(4) Inpatient hospital claims related to adverse events (excludes medicare crossover inpatient hospital claims discussed in subsection (3) of this section). The department applies the following rules for these claims:
(a) When
the department requests information from a hospital regarding adverse events
identified by DOH, the hospital must provide the information requested for any
affected medical assistance client (this includes both fee-for-service clients
and clients enrolled in a managed care organization (MCO) contracted with the
department). If no medical assistance client was affected by an adverse event,
the hospital must provide a written response to the department with an
assurance that no medical assistance clients were affected.
(b) The department does not pay for adverse
events identified by DOH and/or identified through the department's
retrospective utilization review process. Some HACs can become an adverse event
if the:
(i) Patient dies or is seriously
disabled; or
(ii) Level of severity
is great, such as the patient develops level three or level four pressure
ulcers.
(c) The client
cannot be held liable for payment.
(d) A hospital may request a retrospective
utilization review by the department, as described in WAC 388-550-1700(6)(a)
and (b)(iii), from the department or its designee to determine if the hospital
is eligible for a partial payment for the adverse event.
(e) A hospital that requests a department
retrospective utilization review of an adverse event must provide the
department with the hospital's root cause analysis, as described in WAC
246-320-146(3) and
(4), of the adverse event claim.
(f) The health care information that is part
of the retrospective utilization review, including the root cause analysis of
the adverse event claim, is exempt from public disclosure under
RCW
42.56.360(1)(c).
(5) Inpatient hospital claims related to hospital-acquired conditions that do not qualify as an adverse event (excludes medicare crossover inpatient hospital claims discussed in subsection (3) of this section). The department applies the following rules for these claims:
(a) The department reviews POA
indicator codes on inpatient hospital claims in order to determine if a
condition was present or incubating at the time the order for inpatient
admission occurred, if a condition occurred during, or as a result of, hospital
care, or if a condition developed during an outpatient encounter.
(i) All hospitals that have signed a core
provider agreement with the department must provide information to the
department by using POA indicator codes on each claim (refer to the table in
this subsection).
(ii) These POA
indicator codes must designate which procedures or complications were present
on admission, and which occurred during, or as a result of, hospital
care.
(iii) POA indicator codes are
to be assigned to principal and secondary diagnosis (as defined in Section II
of the Official Guidelines for Coding and Reporting), and the external cause of
injury codes.
|
POA Indicator Codes |
|
|
Code |
Reason for Code |
|
Y |
Diagnosis was present at time of inpatient admission. |
|
N |
Diagnosis was not present at time of inpatient admission. |
|
U |
Documentation insufficient to determine if condition was present at the time of inpatient admission. |
|
W |
Clinically undetermined. Provider unable to clinically determine whether or not the condition was present at the time of inpatient admission. |
(b) The department does not make additional
payments for services on inpatient hospital claims that are attributable to
HACs and are coded with POA indicator codes "N" or "U." Specifically, for
hospitals paid under the:
(i) Diagnostic
related group (DRG) payment method, the department does not make additional
payments for complications and comorbidities (CC) and major complications and
comorbidities (MCC).
(ii) Per diem
payment method, the department does not pay for days beyond the average
length-of-stay (LOS) (defined in WAC 388-550-1050 ).
(iii) Departmental weighted costs-to-charges
(DWCC) payment method, the department does not pay for services attributable to
the HAC.
(iv) DRG and per diem
outlier payment methods, the department does not pay for services attributable
to the HAC.
(v) Ratio of
costs-to-charges (RCC) payment method, the department does not pay for services
attributable to the HAC.
(vi) Per
case payment method, the department does not pay for services attributable to
the HAC.
(6) The department denies payment for any HAC that results in death or serious disability.
(7) A hospital that disagrees with a department decision to deny payment or partial payment of an adverse event or hospital-acquired condition may follow the administrative appeal process in WAC 388-502-0220.
11-14-075, recodified as § 182-550-1650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and Centers for Medicare and Medicaid Services (CMS). 09-24-061, § 388-550-1650, filed 11/25/09, effective 1/1/10.
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