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Adverse Events, Hospital-Acquired Conditions, and Present on Admission Indicators. Surgery on wrong body part Surgery on wrong patient Wrong surgery on a patient. Serious reportable adverse events.

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serious reportable adverse events

Surgery on wrong body part

Surgery on wrong patient

Wrong surgery on a patient

Serious reportable adverse events
adverse events

Adverse Events are the events that must be reported to Medicaid by the hospital. These events are clearly identifiable, preventable, and serious in their consequences for patients.

This is a cost containment self reporting mechanism that will be required by hospitals effective July 1, 2010. It will affect inpatient hospital claims only.

POA issues identified in post payment audit may result in a recoupment.

Adverse Events
hospital acquired conditions hac

Hospital-Acquired Conditions are conditions that are reasonably preventable and were not present or identified at the time of admission; but are either present at discharge or documented after admission.

Hospital-Acquired Conditions (HAC)
slide5
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Foreign Object Retained After Surgery
  • Air Embolism
  • Blood Incompatibility
  • Pressure Ulcer Stages III & IV
  • 998.4 (CC)
  • 998.7 (CC)
  • 999.1 (MCC)
  • 999.6 (CC)
  • 707.23 (MCC)
  • 707.24 (MCC)
slide6
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Falls and Trauma:
  • Fracture
  •   - Dislocation
  •   - Intracranial Injury
  •   - Crushing Injury
  •   - Burn
  •   - Electric Shock
  • Codes within these ranges on the CC/MCC list:
  • 800-829
  • 830-839
  • 850-854
  • 925-929
  • 940-949
  • 991-994
slide7
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Catheter-Associated Urinary Tract Infection (UTI)
  • 996.64 (CC)
  • Also excludes the following from acting as a CC/MCC:
  • 112.2 (CC)
  • 590.10 (CC)
  • 590.11 (MCC)
  • 590.2 (MCC)
  • 590.3 (CC)
  • 590.80 (CC)
  • 590.81 (CC)
  • 595.0 (CC)
  • 597.0 (CC)
  • 599.0 (CC)
slide8
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Vascular Catheter-Associated Infection
  • Manifestations of Poor Glycemic Control
  • 999.31 (CC)
  • 250.10-250.13 (MCC)
  • 250.20-250.23 (MCC)
  • 251.0 (CC)
  • 249.10-249.11 (MCC)
  • 249.20-249.21 (MCC)
slide9
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)
  • Surgical Site Infection Following Certain Orthopedic Procedures
  • 519.2 (MCC)

And one of the following procedure codes:

  • 36.10–36.19
  • 996.67 (CC)
  • 998.59 (CC)
  • And one of the following procedure codes:  81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, or 81.85
slide10
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Surgical Site Infection Following Bariatric Surgery for Obesity
  • Principal Diagnosis – 278.01
  • 998.59 9 (CC)
  • And one of the following procedure codes:  44.38, 44.39, 44.95
slide11
Selected HAC

CC/MCC (ICD-9-CM Codes)

  • Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures
  • 415.11 (MCC)
  • 415.19 (MCC)
  • 453.40-453.42 (MCC)
  • And one of the following procedure codes: 00.85-00.87, 81.51-81.52, 81.54
present on admission poa

The Present on Admission (POA) Indicator is defined as a set of specified conditions that are present at the time the order for inpatient hospital admission occurs.

Conditions that develop during an outpatient encounter, including the emergency room, observation, or outpatient surgery, are considered POA.

Present on Admission (POA)
poa continued

If one of the following DX codes are billed in FL 67 on the UB 04 claim form; then a POA indicator must also be in the 8th digit of FL 67 ‘Principal Diagnosis’ and each of the secondary diagnosis fields indicated as “A through Q”.

Medicaid recognizes all POA indicators for reporting purposes.

POA CONTINUED
slide14
If one of the following diagnosis codes is billed on the UB 04 claim form; then a POA indicator must also be indicated:
  • Single Diagnosis Codes and ranges:
  • 249.10-249.11
  • 249.20-249.21
  • 250.10-205.13
  • 250.20-250.23
  • 251.0
  • 707.23
  • 707.24
  • 800-829.1
  • 830-839.9
  • 850-854.1
  • 925-929.9
  • 940-949.5
  • 991-994.9
  • 996.64*
  • 998.4
  • 998.7
  • 999.1
  • 999.31
  • 999.6
continued

*A POA indicator is required UNLESS one of the following diagnosis codes is also present on the claim:

    • 112.2, 590.10, 590.11, 590.2, 590.3, 590.80, 590.81, 595.0, 597.0, or 599.0.
  • If the claim contains one of these diagnosis codes in any diagnosis field, then a POA is not required.
Continued…
slide16

The POA indicator is required for the following diagnosis codes ONLY when surgical ICD-9 surgical procedure codes are billed as described below:

  • 278.01 AND 998.59 and one of the following ICD-9 surgical procedure codes: 44.38, 44.39, or 44.95,
  • 519.2 AND one of the following ICD-9 surgical procedure codes: 36.10-36.19,
  • 996.67 OR
  • 998.59 and one of the following ICD-9 surgical procedure codes:
  • 81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, or 81.85,
  • 415.11 OR
  • 415.19 OR
  • 453.40-453.42 and one of the following ICD-9 surgical procedure codes: 00.85-00.87, 81.51-81.52, 81.54
slide17

The addition of the POA reporting requirement has placed even more emphasis on the importance of accurate and complete medical documentation. POA depends on accurate physician documentation that the condition was present on admission.

  • The provider should document the POA status or the diagnosis at the time of an inpatient admission or in a timely fashion so that it is evident that the diagnosis is present on admission.
slide18

Therefore, the best source for POA information is provider documentation at the time of admission.

  • The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission.
slide19

Since these new requirements focus on hospital quality improvement and risk management, it is important for quality programs to play a role in the POA reporting process. It is crucial for hospitals to work with their coding departments as a joint effort to achieve accurate and complete documentation, code assignment, and reporting in a timely manner.

  • The quality program should also closely monitor the coding and documentation processes to ensure that both are being handled efficiently, and areas where improvement may be needed are identified and addressed immediately.
questions answers
Questions…….…..&………………..answers

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for further information

Please contact

Jerri Jackson, RN, BSN

Associate Director, Institutional Services

Alabama Medicaid Agency

(334) 242-5630

jerri.jackson@medicaid.alabama.gov

for further information: