Provider Notice issued 06/12/12

Chapter H-200, Handbook for Hospital Services Non-Payment for Provider-Preventable Conditions (PPCs)

Provider Bulletin H-200-12-01

To:​ Participating Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers
​Date: ​June 6, 2012
​Re: Chapter H-200, Handbook for Hospital Services Non-Payment for Provider-Preventable Conditions (PPCs)​

This bulletin updates HFS policy and billing instructions relating to Provider-Preventable Conditions (PPCs). Provider-Preventable Conditions are those conditions or events that are considered reasonably preventable through compliance with evidence-based guidelines.

Effective with inpatient admissions on and after July 1, 2012, and to effectuate the purpose of care and services in the best interests of the recipients of medical assistance as stated in 42 CFR Part 447, the department will deny payment to hospitals for the entire inpatient stay if a designated PPC presented during the inpatient admission. This policy applies to all hospitals, all inpatient claims (including Medicare/Medicaid combination claims), and both the DRG and per diem reimbursement methodologies.

HFS will be editing inpatient claims for two categories of PPCs:

  1. PPCs defined as Hospital-Acquired Conditions (HACs): Effective with admissions on and after July 1, 2012, the department will deny the entire inpatient stay if the Present on Admission (POA) indicator for a designated HAC specifies the condition was introduced during the inpatient admission. The department’s designated list of diagnosis codes or diagnosis/procedure code combinations to be utilized as HACs is included with this bulletin and is also posted to the department’s reimbursement Web page.

  2. PPCs defined as Other Provider Preventable Conditions (OPPCs): Effective with admission on and after July 1, 2012, the department will deny payment for claims relating to a wrong surgical procedure performed on a patient; a surgical procedure performed on the wrong patient; or a surgical procedure performed on the wrong body part. Hospitals must submit claims to report these incidents and are instructed to populate the inpatient claims with specific secondary “E” diagnosis codes as appropriate.

Effective July 1, 2012, HFS will make the following claim processing changes. Hospitals are mandated to submit all claims containing the department’s identified PPCs.

  • If no POA indicator is shown with a principal or secondary diagnosis code that requires a POA indictor, the claim will be rejected with error code H25 – POA Present on Admission Indicator Required.

  • A claim containing any diagnosis code or diagnosis code/procedure code combination that is HAC-designated and has an associated POA indicator “N” – No (Not Present at Time of Admission) or “U” – Unknown (Documentation is insufficient to determine if condition is present at time of inpatient admission) will be paid at zero with informational message G35 – Hospital Acquired Condition Non-Payable.

  • A claim containing a secondary diagnosis code of E876.5, E876.6, or E876.7 and has a POA indicator of “N” – No (Not Present at Time of Admission) or “U” – Unknown (Documentation is insufficient to determine if condition is present at time of inpatient admission) will be paid at zero with informational message G46 – Other Provider Preventable Cond Non-Payable.

The Handbook for Hospital Services has been updated and is available on the department’s Web site. Printed copies of this bulletin and replacement pages for the handbook are available upon written request. To ensure delivery, specify a physical street address when making a request for a paper copy. Submit your written request or fax to:

Illinois Department of Healthcare and Family Services

Provider Participation Unit

Post Office Box 19114

Springfield, Illinois 62794-9114

Fax Number (217) 557-8800

E-mail the Provider Participation Unit

Any questions regarding this bulletin should be directed to your facility’s medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

Instructions for updating the Handbook for Hospital Services:

Table of Contents

Remove pages HFS H-200 (iii-iv) and insert new pages HFS H-200 (iii-iv).

H-262.6 Provider-Preventable Conditions (PPCs)

Remove pages HFS H-262 (3-4) and insert new pages HFS H-262 (3-4) and (5-6).

Hospital Acquired Conditions

Effective for Inpatient Admissions On and After July 1, 2012

HAC

Diagnosis Codes

Foreign Object Retained After Surgery

998.4

998.7

Air Embolism

999.1

Blood Incompatibility

999.60

999.61

999.62

999.63

999.69

Pressure Ulcers States III and IV

707.23

707.24

Falls and Trauma:

• Fracture

• Dislocation

• Intracranial Injury

• Crushing Injury

• Burn

• Other Injuries

Codes within these ranges:

• 800-829

• 830-839

• 850-854

• 925-929

• 940-949

• 991-994

Catheter-Associated Urinary Tract Infection (UTI)

996.64

Also excludes the following from acting as a complication or comorbidity or major complication or comorbidity:

112.2

590.10

590.11

590.2

590.3

590.80

590.81

595.0

597.0

599.0

Vascular Catheter-Associated Infection

999.31

Manifestations of Poor Glycemic Control:

  • Diabetic Ketoacidosis

  • Nonketotic Hyperosmolar Coma

  • Hypoglycemic Coma

  • Secondary Diabetes with Ketoacidosis

  • Secondary Diabetes with Hyperosmolarity

  • 250.10-250.13

  • 250.20-250.23

  • 251.0

  • 249.10-249.11

  • 249.20-249.21

Surgical Site Infection, Mediastinitis, following Coronary Artery Bypass Graft (CABG)

519.2

And one of the following procedure codes:

36.10-36.19

Surgical Site Following Certain Orthopedic Procedures:

  • Spine

  • Neck

  • Shoulder

  • Elbow

996.67

998.59

And of the following procedure codes:

81.01-81.08

81.23-81.24

81.31-81.38

81.83

81.85

Surgical Site Infection Following Bariatric Surgery for Obesity:

  • Laparoscopic Gastric Bypass

  • Gastroenterostomy

  • Laparoscopic Gastric Restrictive Surgery

Principal Diagnosis – 278.01

539.01

539.81

998.59

And one of the following procedure codes:

44.38

44.39

44.95

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures:

  • Total Knee Replacement

  • Hip Replacement 415.11

415.13

415.19

453.40-453.42

And one of the following procedure codes:

00.85-00.87

81.51-81.52

81.54