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Reporting and Reimbursement Adjustment for Provider-Preventable Conditions

June 16, 2017

Welfare and Institutions Code 14131.11, as well Title 42 of the Code of Federal Regulations, Sections 434, 438 and 447, require all Medi-Cal providers to report provider-preventable conditions (PPCs) that are associated with claims for Medi-Cal reimbursement or with courses of treatment prescribed to a Medi-Cal beneficiary for which payment would otherwise be available. Providers do not need to report PPCs that existed prior to the initiation of treatment of the beneficiary by the provider.

A provider must report the occurrence of any PPC in any Medi-Cal beneficiary that did not exist prior to the provider initiating treatment. A provider must report the occurrence regardless of whether or not the provider seeks Medi-Cal reimbursement for services to treat the PPC. Reporting a PPC for a Medi-Cal beneficiary does not preclude the reporting of adverse events, pursuant to Health and Safety Code (H&S Code), Section 1279.1, to the California Department of Public Health (CDPH).

A provider reports a PPC by using the Instructions for online reporting of PPCs page of the Department of Health Care Service website. Providers must submit the electronic report after discovering the condition and confirming that the patient is a Medi-Cal beneficiary. Providers with managed care plans (MCP) should also notify the beneficiary’s MCP about the PPC.

Medi-Cal will adjust reimbursement for PPCs as required and defined by federal regulations and state law. Medi-Cal will not adjust reimbursement for PPC-related claims when the provider notes that the PPC existed prior to the provider initiating treatment for the beneficiary. Reimbursement adjustment will be limited to PPCs that would otherwise result in an increase of reimbursement and to the extent that DHCS can reasonably isolate the nonpayment portion of reimbursement directly related to the PPC.

If a Medicare/Medi-Cal crossover claim notes a PPC that was not present prior to the provider’s treatment of the beneficiary, DHCS will exclude the PPC from the reimbursement calculation when it can confirm the increased costs are directly attributable to the PPC.

PPCs are recognized as Health Care-Acquired Conditions (HCACs) only in inpatient hospital settings and Other Provider-Preventable Conditions (OPPCs) in all other health care settings.

  • OPPCs are defined as:
    • Wrong surgical or other invasive procedure performed on a beneficiary
    • Surgical or other invasive procedure performed on the wrong body part
    • Surgical or other invasive procedure performed on the wrong beneficiary
  • HCACs are defined as:
    • Foreign object retained after surgery
    • Air embolism
    • Blood incompatibility
    • Stage III and IV pressure ulcers
    • Falls and trauma that result in fractures, dislocations, intracranial injuries, crushing injuries, burns and electric shock
    • Latrogenic pneumothorax with venous catheterization
    • 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 following:
      • Mediastinitis following coronary artery bypass graft (CABG)
      • Bariatric surgery, including laparoscopic gastric bypass, gastroenterostomy and laparoscopic gastric restrictive surgery
      • Orthopedic procedures, including spine, neck, shoulder, and elbow
      • Cardiac implantable electronic device (CIED) procedures
    • For non-pediatric/obstetric population, deep vein thrombosis (DVT)/ pulmonary embolism (PE) resulting from:
      • Total knee replacement
      • Hip replacement