Nonpayment for Serious Adverse Events

Description

Adverse healthcare events are a leading cause of death and injury in the United States. A November 1999 report by the Institute of Medicine indicated that as many as 98,000 people die in hospitals each year as the result of medical errors. This would make medical errors the eighth leading cause of death in this country. Errors occur not only in hospitals but in other health care settings, such as physicians’ offices, nursing homes, pharmacies, urgent care centers, and care delivered in the home. Unfortunately, very little data exist on the extent of the problem outside of hospitals.

The Institute of Medicine defines medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." An adverse event is defined as "an injury caused by medical management rather than by the underlying disease or condition of the patient." Some adverse events are not preventable and they reflect the risk associated with treatment, such as a life-threatening allergic reaction to a drug when the patient had no known allergies to it. But research clearly shows that the majority of medical errors can be prevented.

In 2002, the National Quality forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report, which outlined a list of adverse events that were "serious, largely preventable and of concern to both the public and health care providers." These events and subsequent revisions to the lists became known as "never events."

“A hospital-acquired condition (HAC) is one of several medical conditions a patient can acquire during a hospital stay that was not present on admission (POA). The Centers for Medicare & Medicaid Services (CMS) have used this designation since October 1, 2008, which may result in adjustments to hospital payments”.

Reimbursement Guidelines

All providers, including, but not limited to inpatient psychiatric hospitals, critical access hospitals, or other facilities granted CMS exemption status, are subject to POA, HAC, and Never Event editing.

Participating providers will not be permitted to receive or retain reimbursement for inpatient or outpatient services related to Never Events. Members will be held harmless for any services related to Never Events.

Unless the diagnosis is exempt per the “POA Exempt Diagnosis” list as published by CMS, all participating providers must populate Present on Admission (POA) indicator on all acute care inpatient hospital claims.

The 14 categories of Hospital Acquired Conditions are listed below. For the complete list see the “Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions” link below. Blue Cross Blue Shield North Carolina (Blue Cross NC) will not reimburse claim lines containing diagnoses or procedures with “N” or “U” POA indicators. The presence of “N” or “U” indicate a condition was hospital acquired and therefore not eligible for reimbursement. 

• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Stage III and IV pressure ulcers
• Falls and trauma
  • Fractures o Dislocations
  • Intracranial injuries
  • Burn
  • Crushing injuries
  • Other injuries 
• Manifestations of poor glycemic control
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
• Catheter-associated urinary tract infection (UTI)
• Vascular catheter-associated infection
• Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
• Surgical site infection following bariatric surgery for obesity
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery
• Surgical site infection following certain orthopedic procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical site infection following cardiac implantable electronic device (CIED)
• Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following certain orthopedic procedures
  • Total knee replacement
  • Hip replacement
• Iatrogenic pneumothorax with venous catheterization

The 3 wrong surgeries included in the list are:

• Wrong surgical procedure performed
• Surgery performed on a wrong patient
• Surgery performed on a wrong body part 

Any professional provider associated with a wrong surgery Never Event (surgeon, anesthesiologist, radiologist, etc.) is not eligible for reimbursement. Reimbursement is also not provided for any services in the operating or procedure room where the wrong surgery error occurs. Members will be held harmless for any services related to wrong surgery Never Events.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

This policy may apply to codes listed on the following CMS websites:

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). 

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). IPPS For FY 2013- 2023 Final Rule.

Applicable service codes: a diagnosis code and/or a modifier is required.

Claims with no POA indicator populated on an inpatient claim will not be accepted. (Refer to link below for the complete list of diagnoses that are considered exempt from POA reporting.)

Related policy

n/a

References

North Carolina General Statute §131E-95

Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. Reducing Hospital-Acquired Conditions | Agency for Healthcare Research and Quality (ahrq.gov)

Institute of Medicine. To Err is Human: Building a Safer Health system. To Err is Human: Building a Safer Health System - PubMed (nih.gov)

Centers for Medicare and Medicaid Services (CMS). Decision memo for wrong surgery performed on a patient (CAG-00401N). NCA - Wrong Surgery Performed on a Patient (CAG-00401N) - Decision Memo (cms.gov)

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). Hospital-Acquired Conditions (Present on Admission Indicator) | CMS

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). IPPS FY 2013-2023 Final Rule. 

Medical Director review 11/2019 

History

4/27/09 New policy issued. BCBSNC has developed a set of principles for use by hospitals in determining preventable adverse events for which full or partial nonpayment is appropriate. The hospital should evaluate each occurrence of an adverse event to determine whether these principles apply to that particular occurrence.

6/22/10 Policy Number(s) removed (amw)

10/12/10 The section that was titled “Principles for Nonpayment for Serious Adverse Events was deleted. The section titled, “Serious Reportable Events in Healthcare” was also deleted. Added section titled, “Hospital Acquired Conditions and Codes.” Reviewed by Senior Medical Director 9/2010. Notification given 10/12/2010 for effective date 1/18/2011. (adn)

6/12/12 Added “outpatient” to the statement in the Hospital Acquired Conditions section to read: Participating acute care inpatient hospitals will not be permitted to receive or retain reimbursement for inpatient or outpatient services related to Never Events. Also deleted “inpatient” from the statement that is revised to read: Members will be held harmless for any inpatient services related to Never Events. The following statement was added following the list of the 3 wrong surgeries: Any professional provider associated with a wrong surgery Never Event (surgeon, anesthesiologist, radiologist, etc.) is not eligible for reimbursement. Reimbursement is also not provided for any services in the operating or procedure room where the wrong surgery error occurs. Members will be held harmless for any services related to wrong surgery Never Events. (adn)

1/29/13 Updated list of hospital acquired conditions and codes per CMS IPPS Fiscal Year 2013 Final Rule. New categories added: surgical site infection following cardiac implantable electronic device and iatrogenic pneumothorax with venous catheterization. Pertinent ICD-9 codes were revised in the following categories: blood incompatibility and vascular catheterassociated infection. (adn)

2/11/14 Routine annual policy review. The section titled “Hospital Acquired Conditions and Codes” that contained a table of ICD-9-CM codes was removed from this policy. (adn)

4/15/14 Link to CMS code information added to Billing/Coding section. (adn)

5/13/14 Policy category changed from “Corporate Medical Policy” to “Corporate Reimbursement Policy”. No changes to policy content. (adn)

11/24/15 Routine review. The list of HACs was reformatted for consistency with the list published on the CMS website. The 2013 list is the most current. No additional HACs added for 2014 and 2015. There is no change to policy content or intent. (adn)

12/30/16 Routine review. No change to policy statement. (an)

12/29/17 Routine review. No change to policy statement. (an)

12/14/18 Routine review. There have been no changes in the HAC list by CMS. 2013 list is the most current. No change to policy statement. (an)

12/2/19 Added final paragraph to Description section. Policy statement revised to read: “Participating providers will not be permitted to receive or retain reimbursement for inpatient or outpatient services related to Never Events. Members will be held harmless for any services related to Never Events.” Added “crushing injuries” to list of HACs. Revised coding information for clarity. Claims with no POA indicator populated on an inpatient claim will not be accepted. Link provided for CMS Present on Admission (POA) Exempt List. Notification given 12/2/2019 for effective date 2/11/2020. (an)

2/25/20 Corrected review dates in header. (an)

12/31/20 Routine policy review. Medical Director approved 12/2020. No changes to policy statement. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel)  

10/1/21 Clarifying statements added to Reimbursement Guidelines section “All providers, including, but not limited to inpatient psychiatric hospitals, critical access hospitals, or other facilities granted CMS exemption status, are subject to POA, HAC, and Never Event editing.” and “Blue Cross Blue Shield North Carolina (Blue Cross NC) will not reimburse claim lines containing diagnoses or procedures with “N” or “U” POA indicators. The presence of “N” or “U” indicate a condition was hospital acquired and therefore not eligible for reimbursement.“ POA indicators added to Billing and Coding section. Notification given 10/1/2021 for effective date 11/30/2021. (eel)

12/30/21 Routine policy review. Medical Director approved. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb) 

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Federal Employee Plan (FEP), or Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.