Library: Policy

317:30-3-62. Provider Preventable Conditions

Revised 3-1-24

(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.

(1) "Health care-acquired conditions (HCAC)" means a condition occurring in any inpatient hospital setting, (identified as a hospital acquired condition by federal regulation and Medicare; other than deep vein thrombosis/pulmonary embolism as related to a total knee replacement or hip replacement surgery in pediatric and obstetric patients.) Medicare's list of hospital acquired conditions is also available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.

(2) "National Quality Forum (NQF)" means the independent, nonpartisan organization tasked with devising a national strategy to set standards for quality improvement and reporting in the healthcare industry.

(3) "Other provider preventable conditions (OPPC)" means the list of serious reportable events in health care as identified by this Section and published by the NQF.

(4) "Present on admission (POA) indicator" means a status code the hospital uses on an inpatient claim that indicates if a condition was present at the time the order for inpatient admission occurs.

(5) "Provider preventable condition (PPC)" means a condition that meets the definition of a "health care-acquired condition" or an "other provider-preventable condition" as defined in this Section.

(b) Health care-acquired conditions (HCAC)

(1) Payment policy. In accordance with 42 C.F.R § 447.26, the Oklahoma Health Care Authority (OHCA) will not reimburse health care professionals and inpatient hospitals for the increased incremental cost of inpatient care services that result when a member is harmed by one (1) of the HCACs listed below.

(A) Foreign object retained after surgery;

(B) Air embolism;

(D) Pressure ulcer stages III & IV;

(E) Falls and trauma; including:

(i) Fracture;

(ii) Dislocation;

(iii) Intracranial injury;

(iv) Crushing injury;

(v) Burn;

(vi) Electric shock;

(F) Catheter-associated urinary tract infection;

(G) Vascular catheter-associated infection;

(H) Manifestations of poor glycemic control; including:

(i) Diabetic ketoacidosis;

(ii) Nonketotic hyperosmolar coma;

(iii) Hypoglycemic coma;

(iv) Secondary diabetes with ketoacidosis;

(v) Secondary diabetes with hyperosmolarity;

(I) Surgical site infection following:

(i) Coronary artery bypass graft-mediastinitis;

(ii) Bariatric surgery; including:

(I) Laparoscopic gastric bypass;

(II) Gastroenterostomy;

(III) Laparoscopic gastric restrictive surgery;

(iii) Orthopedic procedures; including:

(I) Spine;

(II) Neck;

(III) Shoulder;

(IV) Elbow;

(iv) Cardiac implantable electronic device (CIED)

(J) Deep vein thrombosis and pulmonary embolism following:

(i) Total knee replacement with exceptions for pediatric and/or obstetric cases; or

(ii) Hip replacement with exceptions for pediatric and/or obstetric cases.

(K) Iatrogenic pneumothorax with venous catheterization

(2) Billing. Hospitals paid under the diagnosis related grouping (DRG) methodology are required to submit a 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. If a provider in either a fee-for-service or managed care delivery system receives SoonerCare reimbursement for the increased incremental cost of inpatient care services that result when a member is harmed by the HCACs identified in (b)(1) (A)-(K), the provider shall reimburse those costs to the Agency or Contracted Entity.

(3) Dually eligible members. SoonerCare will not act as a secondary payer for Medicare non-payment of HCACs.

(1) Payment policy. In accordance with 42 C.F.R § 447.26, the Agency will not reimburse health care professionals and inpatient hospitals for care related to the treatment of consequences of an OPPC when the condition:

(A) Is identified in the Oklahoma Medicaid State Plan;

(B) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines;

(D) Has a negative consequence for the member;

(E) Is auditable; and

(F) Is included on the list of serious reportable events in health care by the National Quality Forum (NQF). Providers are responsible for keeping abreast of any changes to the list of serious reportable events identified by the NQF. The list of serious reportable events in health care, as of the publishing of this rule, includes surgical or invasive procedure events:

(i) Surgical or other invasive procedure performed on the wrong site;

(ii) Surgical or other invasive procedure performed on the wrong patient;

(iii) Wrong surgical or other invasive procedure performed on a patient;

(2) Billing. For inpatient claims, hospitals are required to bill two (2) claims when the erroneous surgery is reported, one (1) claim with covered services or procedures unrelated to the erroneous surgery, the other claim with the non-covered services or procedures as a no-payment claim. For outpatient and practitioner claims, providers are required to append the applicable Healthcare Common Procedure Coding System (HCPCS) modifiers to all lines related to the erroneous surgery. Claim lines submitted with one (1) of the applicable HCPCS modifiers will be line-item denied. If a provider in either a fee-for-service or managed care delivery system receives SoonerCare reimbursement for patient care or treatment directly related to an identifiable provider-preventable condition that was not present when the individual initiated treatment with that provider, the provider shall reimburse those costs to the Agency or Contracted Entity.

(3) Related claims. Once a claim for the erroneous surgery(s) has been received, OHCA may review member history for related claims as appropriate. Incoming claims for the identified member may be reviewed for an eighteen-month (18-month) period from the date of the surgical error. If such claims are identified to be related to the erroneous surgical procedure(s), OHCA may take appropriate action to deny such claims and recover any overpayments on claims already processed.

(4) Dually eligible members. SoonerCare will not act as a secondary payer for Medicare non-payment of OPPCs.

(d) Reporting. Title 42 of the Code of Federal Regulations, Sections 447, 434 and 438 require providers, in both fee-for-service and managed care delivery systems, to report all PPCs that are associated with claims for SoonerCare payment or with courses of treatment furnished to a SoonerCare member for which Medicaid payment would otherwise be available. The report shall be made to the OHCA regardless of whether the provider seeks SoonerCare reimbursement for services to treat the PPCs. The Agency report form is available for download at https://oklahoma.gov/ohca. Providers must report the following information to the OHCA within 10 days of the occurrence of the event:

(1) Member name and member ID number.

(2) A description of the event.

(3) Dates of services and occurrence of the event.

(4) Attending physician(s).

(5) Facility.

(e) Liability. A provider cannot shift financial liability or responsibility for the non-covered services and treatment to the member if the OHCA has determined that the service is related to a PPC.