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Library: Policy

317:30-3-63. Hospital acquired conditions

Issued 4-1-10

(a) Coverage.  The Oklahoma Health Care Authority (OHCA) will no longer reimburse the extra cost of treating certain categories of conditions that occur while a member is in the hospital.  For discharges, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission.  The claim will be grouped to a DRG as if the diagnosis was not present on the claim.  The selected conditions that OHCA recognizes are those conditions identified as non-payable by Medicare.  OHCA may revise through addition or deletion the selected conditions at any time during the fiscal year.  The following is a complete list of the hospital acquired conditions (HACs) currently recognized by OHCA:

  • (1) Foreign Object Retained After Surgery

  • (2) Air Embolism

  • (3) Blood Incompatibility

  • (4) Pressure Ulcer Stages III & IV

  • (5) Falls and Trauma

    • (A) Fracture

    • (B) Dislocation

    • (C) Intracranial Injury

    • (D) Crushing Injury

    • (E) Burn

    • (F) Electric Shock

  • (6) Catheter-Associated Urinary Tract Infection

  • (7) Vascular Catheter-Associated Infection

  • (8) Manifestations of Poor Glycemic Control

    • (A) Diabetic Ketoacidosis

    • (B) Nonketotic Hyperosmolar Coma

    • (C) Hypoglycemic Coma

    • (D) Secondary Diabetes with Ketoacidosis

    • (E) Secondary Diabetes with Hyperosmolarity

  • (9) Surgical Site Infection Following:

    • (A) Coronary Artery Bypass Graft- Mediastinitis

    • (B) Bariatric Surgery

      • (i) Laparoscopic Gastric Bypass

      • (ii) Gastroenterostomy

      • (iii) Laparoscopic Gastric Restrictive Surgery

    • (C) Orthopedic Procedures

      • (i) Spine

      • (ii) Neck

      • (iii) Shoulder

      • (iv) Elbow

  • (10) Deep Vein Thrombosis and Pulmonary Embolism

    • (A) Total Knee Replacement

    • (B) Hip Replacement

(b) Billing.  Hospitals paid under the diagnosis related grouping (DRG) methodology are required to submit a present on admission (POA) indicator for the principal diagnosis code and every secondary diagnosis code for all discharges.  A valid POA indicator is required on all inpatient hospital claims.  Claims with no valid POA indicator will be denied.  For all claims involving inpatient admissions, OHCA will group diagnoses into the proper DRG using the POA indicator. 

(c) Dually eligible members.  SoonerCare will not act as a secondary payer for Medicare non-payment of the aforementioned hospital acquired conditions.

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