9201 HEALTH CARE ACQUIRED CONDITIONS

9201.1 HCACs subject to payment adjustments under the District of Columbia's Medicaid program shall include those preventable medical conditions that were not present upon admission to an inpatient hospital setting, but were acquired after an inpatient admission occurs.

9201.2 HCACs shall consist of diagnoses identified by a secondary diagnostic code.

9201.3 DHCF shall adjust provider payments for the portion of the claims directly related to treatment for, and related to, the following HCACs:

1. (a) Foreign object retained after surgery;
2. (b) Air embolism;
3. (c) Blood incompatibility;
4. (d) Catheter-associated urinary tract infection;
5. (e) Pressure Ulcer Stages III or IV;
6. (f) Vascular catheter-associated infection;
7. (g) Mediastinitis after coronary artery bypass graft;
8. (h) Falls and trauma resulting in fractures, dislocations, intracranial injury, crushing injury, burn, and other unspecified effects of external causes;
9. (i) Manifestations of poor glycemic control;
10. (j) Surgical site infection following spine, neck, shoulder, or elbow orthopedic procedures;

11. (k) Surgical site infection following bariatric surgery for obesity; and

12. (l) Deep vein thrombosis and pulmonary embolism following a total knee or hip replacement, except for pediatric (individuals under the age of twenty-one (21)) and obstetric populations.

9201.4 The following provider types shall be denied reimbursement for the portion of a

claim attributed to HCACs:

(a) Hospitals paid on a diagnosis-related group (DRG) basis; and

(b) Hospitals paid on a non-DRG basis.

9201.5 For all claims submitted on or after July 1, 2012, each provider shall collect and record information related to HCACs in the present on admission (POA) indicator field and on the secondary diagnosis indicator field on all applicable claims, regardless of whether the claims are submitted in a hardcopy or electronic format.

9201.6 Additional information, including medical records, may be requested by DHCF regarding claims for payment made on or after July 1, 2012. Providers must collect and maintain information regarding the diagnosis underlying each claim made on or after July 1, 2012, including whether the diagnosis was POA, or if the provider was unable to make such a determination due to clinical reasons or insufficient documentation.

9201.7 The POA and secondary diagnosis indicator requirement shall be implemented pursuant to additional guidance issued by the DHCF.

9201.8 A provider that fails to collect and record information in the POA indicator field or secondary diagnosis indicator field, in accordance with this section, shall be denied payment for the associated claim.

SOURCE: Final Rulemaking published at 59 DCR 14960 (December 21, 2012).