Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Hospital Acquired Conditions (HACs):

a)    These are secondary conditions that are not present at the time of admission but occur during the hospital stay. In many cases HACs are commonly seen complications that, unfortunately, cannot be prevented even with the best of care. 

b)    Of the many possible HACs, there is a subset which could reasonably have been prevented through application of widely accepted, evidence-based guidelines or safety procedures.

c)    QualChoice will identify these events and apply a no payment policy for preventable HACs at in network hospitals (no additional payment beyond what is routinely paid for the primary admitting diagnosis or procedure). This will bring QualChoice policy more closely in line with CMS (Medicare/Medicaid) policy regarding preventable HACs. 

d)    CMS currently recognizes 14 major categories of preventable HACs:
HAC 01 – Foreign body retained following surgery
HAC 02 – Air embolism
HAC 03 – Blood incompatibility
HAC 04 – Stage III and IV pressure ulcers
HAC 05 – Falls and trauma
HAC 06 – Catheter-associated UTI (CAUTI)
HAC 07 – Vascular catheter-associated infection
HAC 08 – Surgical site infection (SSI): Mediastinitis following CABG
HAC 09 – Manifestations of poor glycemic control
HAC 10 – Deep vein thrombosis (DVT) or pulmonary embolism (PE) with total

                 knee or hip replacement
HAC 11 – Surgical site infection (SSI): following bariatric surgery
HAC 12 – Surgical site infection (SSI): following certain orthopedic procedures of

                 spine, shoulder or elbow
HAC 13 – Surgical site infection (SSI): following cardiac implantable electronic

                 device (CIED) procedures
HAC 14 – Iatrogenic pneumothorax with venous catheterization

The above list is subject to change over time and is not all inclusive.  Some HACs are identified simply by diagnosis codes not present on admission while others may only be identified when specific procedure codes are associated with specific diagnosis codes.

Preventable HACs Identified During Concurrent Review

During the course of a hospitalization, hospitals may ask for prior approval of additional days beyond what was initially expected/approved.  This process is called concurrent review.  If during the process of concurrent review, it becomes apparent there are preventable HACs involved, prior approval of additional days cannot be granted because there is no ability to accurately determine which additional days are a result of preventable HACs (hospital responsibility) and which are not.  In these situations, the only fair and accurate way to determine medically necessary hospital days and services is through a retrospective review of the medical records and itemized charges.  Despite lack of concurrent approval of for additional days, the hospital still has a clinical, ethical and legal responsibility to continue providing necessary patient care. 

Preventable HACs Identified During Retrospective Review

While preventable HACs can be identified during concurrent review, they may also be identified retrospectively at the time of claim submission.  If a submitted claim is suggestive of preventable HACs, QualChoice will not process the claim until medical records and itemized statements are provided for review.   This review will determine which services were medically necessary services and not a result of preventable HACs.

Days or services that are related to preventable HACs will not be approved.  Hospitals must assume responsibility for preventable HACs and cannot pass this responsibility on to insurers or to patients.

1)    Hospital Acquired Conditions (HACs):

a)    HACs are conditions that are not present when patients are admitted to a hospital, but become present during the course of the patient’s stay.

2)    Beginning 1/1/2010 all hospitals (including Critical Access Hospitals, specialty hospitals and children’s hospitals) will be required to report the POA (Present On Admission) indicator on all claims using the CMS rules:

a)    The POA indicator is submitted in field 67 of the UB-04 and in segment K3 in the 2300 loop, data element K301 for the 837I electronic claim submission.

b)    The values for these fields are as follows:

·          Y = Present at the time of inpatient admission

·          N = Not present at the time of inpatient admission

·          U = Documentation is insufficient to determine if condition is present on  

        admission

·          W = Provider is unable to clinically determine whether condition was present

         on admission or not

·           1 = Exempt from POA reporting. Unreported/Not used.

c)     See appendix A for more information.

3)    Claims submitted without appropriate POA indicator will be considered incomplete and denied beginning 4/1/2010.

4)    Any of the HAC diagnoses without Y in the POA field will result in the claim defaulting to only allow the authorized payment or days for any primary admitting diagnosis or procedure.

When there is a documented preventable HAC that was not POA, it will be assumed that extra hospital days, corrective procedures, and/or additional costs could have been prevented and are therefore not medically necessary.

a)    QualChoice will reimburse physicians who provide follow-up care necessitated by the occurrence of a HAC and/or never event when they were not responsible for the HAC and/or never event (see BI252 for never events).

5)    Examples of preventable HACs: are provided on a code Table.

6)    Claim submission requirements are in Appendix A

Preventable HACs Identified During Concurrent Review
During the course of a hospitalization, hospitals may ask for prior approval of additional days beyond what was initially expected/approved.  This process is called concurrent review.  If during the process of concurrent review, it becomes apparent there are preventable HACs involved, prior approval of additional days cannot be granted because there is no ability to accurately determine which additional days are a result of preventable HACs (hospital responsibility) and which are not.  In these situations, the only fair and accurate way to determine medically necessary hospital days and services is through a retrospective review of the medical records and itemized charges.  Despite lack of concurrent approval of for additional days, the hospital still has a clinical, ethical and legal responsibility to continue providing necessary patient care. 

 

Preventable HACs Identified During Retrospective Review
While preventable HACs can be identified during concurrent review, they may also be identified retrospectively at the time of claim submission.  If a submitted claim is suggestive of preventable HACs, QualChoice will not process the claim until medical records and itemized statements are provided for review.   This review will determine which services were medically necessary services and not a result of preventable HACs.

Days or services that are related to preventable HACs will not be approved.  Hospitals must assume responsibility for preventable HACs and cannot pass this responsibility on to insurers or to patients.

1.    CMS –Hospital Acquired Conditions background at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

2.    Most Current CMS HAC list:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html

3.    CMS Hospital Acquired Conditions – Trauma Code Descriptions. At: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalAcqConTraumaCodes.pdf.

4.    Norton E., Ann Surg. 2007 Apr; 245(4):526-32.

5.    15. Michaels RK, et. AORN J. 2006 May; 83(5):1115-8, 1121-2.

6.    16. Seiden, SC and Barah, P, Arch Surg. 2006 Sep; 141(9):931-9.

7.    17. Kwaan MR et. al., Arch Surg. 2006 Apr; 141(4):353-7.