9202

OTHER PROVIDER PREVENTABLE CONDITIONS

9202.1 Other Provider Preventable Conditions (OPPCs) shall include erroneous medical procedures as identified by Medicare under three (3) national coverage determinations (NCDs) that deny coverage when a practitioner performs the wrong procedure in any health care setting including outpatient or inpatient hospitals, ambulatory surgical centers, and practitioner settings.

9202.2 DHCF shall deny payment for claims associated with the following OPPCs:

(a) Wrong surgical procedure;

(b) Correct procedure performed on the wrong patient; and

(c) Correct procedure performed on the wrong body part.

9202.3 The following provider types shall be denied compensation for claims associated with OPPCs:

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

(b) Hospitals paid on a non-DRG basis; and

(c) Other providers, regardless of whether they are paid on a fee-for-service or capitated basis.

9202.4 For all claims submitted on or after July 1, 2012, providers shall report OPPCs by using modifiers and E-codes on paper and electronic claim forms that refer to the prohibited procedures described in § 9202.2.

9202.5 The OPPC modifier and E-code requirement shall be implemented pursuant to additional guidance issued by DHCF.

9202.6 DHCF or its agent may request additional information, including medical records for admissions and/or outpatient procedures, in order to verify the occurrence or absence of an OPPC. Providers must collect and maintain information regarding the OPPC associated with each claim submitted on or after July 1, 2012, including reference to the associated prohibited procedure described in § 9202.2.

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