Policy No: 106
Originally created: 04/01/2009
Last Reviewed: 05/01/2020
Last Revised: 05/01/2020
Effective Date: 09/01/2020
This policy applies to all physicians, other health care professionals, hospitals and other facilities.
Adverse Event – An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care. This includes never events; hospital-acquired conditions; events that required life-sustaining intervention; and events that caused prolonged hospital stays, permanent harm, or death (see Reference #1). This would also include an iatrogenic complication.
Preventable event – A preventable event is an adverse event that could have been prevented through the application of evidence-based guidelines (see Reference #16).
Never Event/Sentinel Event/Serious Reportable Event (SRE) – “Adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable (see Reference #3). Specific Serious Reportable Events are commonly referred to as “never events” by CMS (see Reference #4).
Hospital Acquired Condition (HAC) – 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)(see Reference #2). HACs include preventable infections and medical errors. HACs are reported by the hospital or facility through claims submission with the use of a Present on Admission (POA) Indicator.
Iatrogenic Complication – Any adverse conditions which are the direct result of treatment by a physician or other health care professional.
Provider – defined as health system, or by other providers in its health system, or by entity wholly owned or wholly operated by Provider/health system, or by another provider under arrangements with Provider.
Note: This policy is not effective until 9/1/2020. To view the current policy, click here:
Our health plan believes that when a member enters a facility for treatment of a medical problem, the member should not experience a preventable adverse event during the member’s stay. Accordingly, our health plan expects all providers to take proper precautions to ensure a preventable adverse event does not occur.
Our health plan will not reimburse providers for a preventable adverse event. All providers are required to hold members harmless for any services related to preventable adverse events. As part of our health plan’s commitment to improving the quality of care available to members, we have adopted reimbursement policies that encourage providers to reduce the incidence of preventable adverse events. Noncovered procedures/services include but are not limited to:
- All adverse event related services provided in the operating room when an adverse event occurs are considered not covered
- All providers in the operating room when the adverse event occurs, who could bill individually for their services, are not eligible for payment for services related to the adverse event.
- All adverse event related services provided during the same hospitalization in which the adverse event occurred are not covered
Providers should note that adverse event related services do not include performance of the procedure, i.e. originally planned and completed procedure(s), (see Reference #17).
When a preventable adverse event occurs, the case will be reimbursed as though the secondary preventable adverse event diagnosis is not present and we will consider coverage for services not related to preventable adverse event, if itemized statements are submitted with the claim.
Our health plan will consider reimbursement for anticipated preventable adverse events after high-risk non-elective procedures, such as repair of major trauma. The below preventable adverse event list is applied as a guide, for determining which claims will be reviewed.
If provider was not the primary provider performing the service causing the preventable adverse event and/or the provider where the preventable adverse event occurred, providers will be reimbursed for costs incurred to treat preventable adverse events.
Our health plan requires diagnosis codes on all provider claims in order to determine if a preventable adverse event occurred, as mandated by official coding guidelines.
The relevant ICD diagnosis code for an ‘external cause of injury code’ is required to be submitted on all applicable claims as the diagnosis in the secondary position to indicate that a preventable adverse event has occurred.
Providers are required to submit a Present on Admission (POA) Indicator on all claims in which a preventable adverse event occurred. POA indicators are assigned to the principal and secondary diagnoses (see Reference #6).
POA Indicator Options and Descriptions:
- Y = Diagnosis was present at the time of inpatient admission
- N = Diagnosis was not present at the time of inpatient admission
- U = Documentation insufficient to determine if the condition was present at the time of inpatient admission
W = Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission (see Reference #6).
The following are exempt from the POA indicator options above:
- Critical Access Hospitals
- Long Term Care Hospitals
- Maryland Waiver Hospitals
- Cancer Hospitals
- Children’s Inpatient Facilities
- Religious Non-Medical Health Care Institutions
- Inpatient Psychiatric Hospitals
- Inpatient Rehabilitation Facilities
Veterans Administration/Department of Defense Hospital
Never Event/Sentinel Event/Serious Reportable Event (SRE) (see Reference #4)
include, but are not limited to:
- Surgery performed on the wrong patient
- Surgery performed on the wrong body part
Wrong surgery performed on a patient
Preventable adverse events include (see Reference #16), but not limited to:
- Foreign Object Unintentionally Retained After Surgery
- Air Embolism
- Blood Incompatibility
- Stage III and IV Pressure Ulcers
- Falls and Trauma
- Intracranial Injuries
- 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
- Laparoscopic Gastric Restrictive Surgery
- Surgical Site Infection Following Certain Orthopedic Procedures
- 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 Appendix A table below is the Centers for Medicare & Medicaid Services (CMS) Hospital Acquired Conditions list. The HAC information includes, but may not be all inclusive, hospital acquired conditions and diagnosis codes.
Foreign object retained after surgery
Stage III and IV pressure ulcers
Falls and trauma
Catheter-associated urinary traction infection (UTI)
Vascular catheter-associated infection
Surgical site infection-mediastinitis after coronary bypass graft (CABG)
Manifestations of poor glycemic control
Deep vein thrombosis (DVT)/pulmonary embolism (PE) with total knee or hip replacement
Surgical site infection - bariatric surgery
Surgical site infection - certain orthopedic procedures of spine, shoulder and elbow
Surgical site infection (SSI) following cardiac implantable electronic device (CIED) procedures
Iatrogenic pneumothorax w/venous catheterization
- Spotlight On... Adverse Events (n.d.), from Office of the Inspector General
- Frequently Asked Questions. Deficit Reduction Act (DRA) Hospital-Acquired Condition (HAC), from CMS.gov
- Never Events, from Agency for Healthcare Research and Quality (AHRQ), AHRQ.gov
- Serious Reportable Adverse Events in Health Care, vol 4, Kizer, Stegun from Agency for Healthcare Research and Quality (AHRQ), AHRQ.gov
- Centers for Medicare & Medicaid Services (CMS) Coverage Decision Memos: NCA Tracking Nos. CAG-00401N, CAG-00402N, CAG-00403N
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision, MLN Fact Sheet
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator), Hospital-Acquired Conditions
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator, Coding
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator, ICD-10 HAC List
- Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Wrong Surgical or Other Invasive Procedure Performed on a Patient (140.6)
- Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Surgical or Other Invasive Procedure Performed on the Wrong Body Part (140.7)
- Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Surgical or Other Invasive Procedure Performed on the Wrong Patient (140.8)
- ICD-10-CM Official Guidelines for Coding and Reporting 2018, Centers for Medicare & Medicaid Services
- U.S. Deparment of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ), Patient Safey Primer, Never Events
- Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions
Centers for Medicare & Medicaid Services (CMS), Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgery or Other Invasive Procedure Performed on the Wrong Body Part; and Surgical or Other Invasive Procedure Performed on the Wrong Patient – JA6405