Payment Policy for Provider Preventable Conditions

PURPOSE: This rule establishes the MO HealthNet payment policy for services provided by acute care hospitals or ambulatory surgical centers that result in Provider Preventable Conditions, errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. (A) “Provider Preventable Conditions (PPC)” is an umbrella term for hospital and non-hospital acquired conditions identified by the state for nonpayment to ensure the high quality of Medicaid services. PPCs include two (2) distinct categories, Health Care-Acquired Conditions (HCAC) and Other Provider-Preventable Conditions (OPPC). (B) “Health Care-Acquired Conditions (HCAC)” means conditions that occurred during a Medicaid inpatient hospital stay. HCACs are set forth in the most current list of Medicare Hospital Acquired Conditions, with the exception of Deep Vein Thrombosis/Pulmonary Embolism following total knee replacement or hip replacement in pediatric and obstetric patients, as the minimum requirements for states’ PPC nonpayment program. (C) “Other Provider-Preventable Conditions (OPPC)” means conditions occurring in any health care setting that include, at a minimum, wrong surgical or other invasive procedure performed on a patient, surgical or other invasive procedure performed on the wrong body part, surgical or other invasive procedure performed on the wrong patient pursuant to 42 CFR 447.26(b). (2) Payment to hospitals enrolled as MO HealthNet providers for care related only to the treatment of the consequences of a HCAC will be denied or recovered by the MO HealthNet Division when the HCAC is determined to have occurred during an inpatient hospital stay and would otherwise result in an increase in payment. HCAC conditions are identified in the list of Medicare Hospital Acquired Conditions, which is incorporated by reference and made part of this rule as published by the Centers for Medicare & Medicaid Services (CMS), 7500 Security Boulevard, Baltimore, MD 21244, November 13, 2024. This rule does not incorporate any subsequent amendments or additions. (A) Hospitals enrolled as MO HealthNet providers shall include the “Present on Admission” (POA) indicator on the CMS 1450 UB-04 or electronic equivalent when submitting inpatient claims for payment. The POA indicator is to be used according to the Official Coding Guidelines for Coding and Reporting and the Center for Medicare & Medicaid Services (CMS) guidelines. The POA indicator prompts review of inpatient hospital claims with a HCAC diagnosis code. (B) All MO HealthNet enrolled hospitals must report HCACs on claims submitted to MO HealthNet for consideration of payment. (C) The MO HealthNet Division, or its designee, will identify the occurrence of HCACs based on the POA indicator, and calculate the payment recoupments based on the facts of each HCAC, for hospitals reimbursed on a per diem. (D) The MO HealthNet Division, or its designee, will identify the occurrence for HCACs for hospitals paid on a Diagnosis Related Group (DRG) by identified diagnosis codes. The identified diagnosis code related to the HCAC will be excluded from the claim prior to assigning the All Patient Refined Diagnosis Related Group (APR-DRG) and severity level, which determines the level of payment to the provider. (3) Payment to hospitals enrolled as MO HealthNet providers for care related only to the treatment of the consequences of an Other Provider-Preventable Condition (OPPC) will be denied or recovered by the MO HealthNet Division when the OPPC is determined to— (A) Be within the control of the hospital; (B) Have occurred during an inpatient hospital admission, outpatient hospital care, or care in an ambulatory surgical center; (C) Have resulted in serious harm; (D) Otherwise result in an increase in payment of the identified OPPC; and (E) Be a wrong surgical or other invasive procedure performed on a patient, surgical or other invasive procedure performed on the wrong body part, surgical or other invasive procedure performed on the wrong patient. (4) Other Provider-Preventable Conditions (OPPC) are to be billed as follows: (A) Medical claims using the CMS 1500 claim form must be billed with the surgical procedure code and modifier which indicates the type of OPPC: modifier PA (wrong body part), PB (wrong patient), or PC (wrong surgery), AND/OR at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part must be present as one (1) of the first four (4) diagnosis codes on the claim; (B) Outpatient hospital claims using the CMS 1450 UB-04 claim form or its electronic equivalent must be billed with at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim; (C) Inpatient hospital claims, using the CMS 1450 UB-04 claim form or its electronic equivalent must be billed with a type of bill 0110. 1. If there are covered services or procedures provided during the same stay as the OPPC, then the facility must submit two (2) claims; one (1) claim with covered services unrelated to the OPPC event and the other claim for any and all services related to the OPPC event. 2. The Type of Bill 0110 claim must also contain one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim; and (D) The MO HealthNet Division will identify the occurrence of OPPCs based on the type of bill, diagnoses, procedures, and Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) modifiers submitted on the claim. Payment for the claims will be denied, if appropriate. (5) A MO HealthNet participant shall not be liable for payment for an item or service related to an OPPC or HCAC or the treatment of consequences of an OPPC or HCAC that would have been otherwise payable by the MO HealthNet Division. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2025.* Material in this rule originally filed as 13 CSR 70-15.200. Original rule filed Nov. 30, 2011, effective June 30, 2012. Amended: Filed Aug. 28, 2018, effective April 30, 2019. Amended: Filed Nov. 14, 2019, effective May 30, 2020. Amended: Filed Nov. 13, 2020, effective May 30, 2021. Amended: Filed Nov. 22, 2021, effective June 30, 2022. Amended: Filed Dec. 15, 2022, effective July 30, 2023. Amended: Filed Nov. 6, 2023, effective May 30, 2024. Amended: Filed July 16, 2025, effective Feb. 28, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.