PURPOSE: This rule establishes the MO HealthNet payment policy for services provided by acute care hospitals or ambulatory surgical centers that result in Provider Preventable Conditions, errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.

1. (1) Definitions.

   1. (A) Provider Preventable Conditions (PPC). An umbrella term for hospital and non-hospital acquired conditions identified by the state for nonpayment to ensure the high quality of Medicaid services. PPCs include two (2) distinct categories, Health Care-Acquired Conditions (HCAC) and Other Provider-Preventable Conditions (OPPC).
   2. (B) Health Care-Acquired Conditions (HCAC). Apply to conditions that occurred during a Medicaid inpatient hospital stay. HCACs are defined as the full list of Medicare Hospital Acquired Conditions, with the exception of Deep Vein Thrombosis/Pulmonary Embolism following total knee replacement or hip replacement in pediatric and obstetric patients, as the minimum requirements for states’ PPC nonpayment program.
   3. (C) Other Provider-Preventable Conditions (OPPC). This includes the list of Serious Reportable Events in Healthcare as published by the National Quality Forum. These conditions apply broadly to Medicaid inpatient and outpatient health care settings where these events may occur.
   4. (D) Adverse event. A discrete, auditable, and clearly defined occurrence as identified by the National Quality Forum in its list of serious adverse events in health care, as of December 15, 2008 (and as further defined by the criteria and implementation guidance of Table 1 of the National Quality Forum’s publication “Serious Reportable Events in Healthcare: 2006 Update” which is available at http://www.qualityforum.org/publications/reports/sre_2006.asp), or an event identified by the Centers for Medicare and Medicaid Services, as of December 15, 2008, that leads to a negative consequence of care resulting in an unintended injury or illness which was preventable.
   5. (E) Preventable. An event that reasonably could have been anticipated and avoided by the establishment and implementation of appropriate policies, procedures, and protocols by a hospital or by staff conformance to established hospital policies, procedures, and protocols.
   6. (F) Serious. An adverse event that results in death or loss of a body part, disability, or loss of bodily function lasting more than seven (7) days or, for a hospital patient, the loss of bodily function is still present at the time of discharge from a hospital.
   7. (G) Healthcare facility. For purposes of the regulation shall mean a hospital or ambulatory surgical center.

2. (2) Payment to hospitals enrolled as MO HealthNet providers for care related only to the treatment of the consequences of a HCAC will be denied or recovered by the MO Health- Net Division when the HCAC is determined to have occurred during an inpatient hospital stay.

   1. (A) HCAC conditions include:

      1. 1. Foreign object retained after surgery;
      2. 2. Air embolism;
      3. 3. Blood incompatibility;
      4. 4. Stage III and IV pressure ulcers;

      5. 5. Falls and trauma—

         1. A. Fractures;
         2. B. Dislocations;
         3. C. Intracranial Injuries;
         4. D. Crushing Injuries;
         5. E. Burns; or
         6. F. Electric Shock;
      6. 6. Catheter-associated Urinary Tract

Infection;

1. 7. Vascular catheter-associated infec-

tion;

1. 8. Manifestations of poor glycemic con-

trol—

1. A. Diabetic Ketoacidosis;
2. B. Nonketotic Hyperosmolar coma;
3. C. Hypoglycemic coma;
4. D. Secondary diabetes with ketoaci-

dosis; or

1. E. Secondary diabetes with hyperos-

molarity;

1. 9. Surgical site infection following:

   1. A. Coronary Artery Bypass Graft

(CABG)—Mediastinitis;

1. B. Bariatric surgery—

   1. (I) Laparoscopic gastric Bypass;
   2. (II) Gastroenterostomy; or
   3. (III) Laparoscopic gastric restric-

tive surgery; or

1. C. Orthopedic procedures—

   1. (I) Spine;
   2. (II) Neck;
   3. (III) Shoulder; or
   4. (IV) Elbow; and
2. 10. Deep Vein Thrombosis (DVT)/Pul-

monary Embolism (PE) excluding those in pediatric and obstetric patients following:

1. A. Total knee replacement; or
2. B. Hip replacement.
3. (B) Hospitals enrolled as MO HealthNet providers shall include the “Present on Admission” (POA) indicator on the CMS 1450 UB-04 or electronic equivalent when submitting inpatient claims for payment beginning July 1, 2010. The POA indicator is to be used according to the Official Coding Guidelines for Coding and Reporting and the CMS guidelines. The POA indicator will prompt review of inpatient hospital claims with an HCAC diagnosis code when appropriate according to the CMS guidelines.
4. (C) HCACs are based on Medicare inpatient prospective payment system rules effective October 1, 2010 (FY 2011), published in the Federal Register, 75:157 (Aug. 16, 2010), pp. 50084–50085, with the inclusion of present on admission (POA) indicators as provided by the final regulation published in the Federal Register, 76:108 (June 6, 2011), pp. 32816–32838. Unlike Medicare, all MO HealthNet enrolled hospitals must report the above mentioned HCACs on claims submitted to MO HealthNet for consideration of payment.

1. (3) Payment to hospitals or ambulatory surgical centers enrolled as MO HealthNet providers for care related only to the treatment of the consequences of an Other Provider-Preventable Condition such as a serious adverse event will be denied or recovered by the MO HealthNet Division when the serious adverse event is determined to—

   1. (A) Be preventable;
   2. (B) Be within the control of the hospital or ambulatory surgical center;
   3. (C) Have occurred during an inpatient hospital admission, outpatient hospital care, or care in an ambulatory surgical center;
   4. (D) Have resulted in serious harm; and

   5. (E) Be included on the National Quality Forum list of Serious Reportable Events as of December 15, 2008, non-payable by Medicare as of December 15, 2008. The National Quality Forum list of serious reportable events as of December 15, 2008, includes:

      1. 1. Surgery performed on the wrong

body part;

1. 2. Surgery performed on the wrong

patient;

1. 3. Wrong surgical procedure on a

patient;

1. 4. Foreign object left in a patient after

surgery or other procedure;

1. 5. Intraoperative or immediately post-

operative death in a normal health patient;

1. 6. Patient death or serious disability

associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility;

1. 7. Patient death or serious disability

associated with the use or function of a device in patient care in which the device is used or functions other than as intended;

1. 8. Patient death or serious disability

associated with intravascular air embolism that occurs while being cared for in a healthcare facility;

1. 9. Infant discharged to the wrong per-

son;

1. 10. Patient death or serious disability

associated with patient elopement (disappearance) for more than four (4) hours;

1. 11. Patient suicide or attempted suicide

resulting in serious disability, while being cared for in a healthcare facility;

1. 12. Patient death or serious disability

associated with a medication error (error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration);

1. 13. Patient death or serious disability

associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products;

1. 14. Maternal death or serious disability

associated with labor or delivery on a lowrisk pregnancy while being cared for in a healthcare facility;

1. 15. Patient death or serious disability

associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility;

1. 16. Death or serious disability (Ker-

nicterus) associated with failure to identify and treat hyperbilirubinemia in neonates;

1. 17. Stage III or IV pressure ulcers

acquired after admission to a healthcare facility;

1. 18. Patient death or serious disability

due to spinal manipulative therapy;

1. 19. Patient death or serious disability

associated with an electric shock while being cared for in a healthcare facility;

1. 20. Any incident in which a line desig-

nated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances;

1. 21. Patient death or serious disability

associated with a burn incurred from any and Procedure of General Applicability

source while being cared for in a healthcare facility;

1. 22. Patient death associated with a fall

while being cared for in a healthcare facility;

1. 23. Patient death or serious disability

associated with the use of restraints or bedrails while being cared for in a healthcare facility;

1. 24. Any instance of care ordered by or

provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider;

1. 25. Abduction of a patient of any age; or
2. 26. Sexual assault on a patient within or

on the grounds of a healthcare facility;

1. (F) Other Provider-Preventable Conditions (OPPC) or serious adverse events are to be billed as follows:

   1. 1. Medical claims using the CMS 1500

claim form, must be billed with the surgical procedure code and modifier which indicates the type of serious adverse event: modifier PA (wrong body part), PB (wrong patient), or PC (wrong surgery), AND/OR at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part must be present as one of the first four (4) diagnosis codes on the claim;

1. 2. Outpatient hospital claims using the

CMS 1450 UB-04 claim form or its electronic equivalent must be billed with at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim; and

1. 3. Inpatient hospital claims, using the

CMS 1450 UB-04 claim form or its electronic equivalent must be billed with a type of bill 0110.

1. A. If there are covered services or

procedures provided during the same stay as the serious adverse event service, then the facility must submit two (2) claims; one (1) claim with covered services unrelated to the OPPC event and the other claim for any and all services related to the OPPC event.

1. B. The Type of Bill 0110 claim must

also contain one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim.

1. (4) A MO HealthNet participant shall not be liable for payment for an item or service related to an OPPC or HCAC or the treatment of consequences of an OPPC or HCAC that would have been otherwise payable by the MO HealthNet Division.
2. (5) The review process for Provider Preventable Conditions (PPC) will include a review of the claim and, if applicable, any information provided during the inpatient certification review to determine if the length of stay was extended by the PPC. Medical records will be requested from the provider as needed to complete the review. Providers will be required to submit the medical records to the MO HealthNet Division within thirty (30) days of receipt of the request for records. Medical records will be reviewed by clinically appropriate medical professionals within the MO HealthNet Division or its contracted medical consultants to assess the quality of medical care provided and the circumstances surrounding that care. MO HealthNet payment denials or recoupments will be calculated by the MO HealthNet Division based on the facts of each OPPC or HCAC. The calculation of the denial of payment or recoupment will be reviewed by the MO HealthNet Division Medical Director and the MO HealthNet Division Director after consideration of the review findings provided by the clinical staff who completed the review. The final decision of the division regarding the denial of payment or recoupment shall be subject to review by the Administrative Hearing Commission pursuant to the provisions of section 208.156, RSMo. Such payment limitation shall only apply to the hospital or ambulatory surgical center where the OPPC or HCAC occurred and shall not apply to care provided by other hospitals should the patient subsequently be transferred or admitted to another hospital for needed care.
3. (6) A MO HealthNet participant shall not be liable for payment, and must not be billed, for any item or service related to a PPC.

AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2011.* Material in this rule originally filed as 13 CSR 70-15.200. Original rule filed Nov. 30, 2011, effective June 30, 2012.

*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.