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Official Notice regarding Medicaid Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions

Official Notice

ON-006-12

Page 3 of 3

Division of Medical Services

Program Development & Quality Assurance

P.O. Box 1437, Slot S-295 · Little Rock, AR 72203-1437

501-682-8368 · Fax: 501-682-2480

OFFICIAL NOTICE

TO: Health Care Providers – AHEC, Ambulatory Surgical Center, Chiropractor, Critical Access Hospital (CAH), CRNA, Dentist, Durable Medical Equipment, End Stage Renal Disease (ESRD), FQHC, Hospital, Nurse Practitioner, Oral Surgeon, Outpatient Hospital, Physician/Independent Lab/CRNA/Radiation Therapy Center, Private Duty Nursing, Rural Health Clinic

DATE: July 1, 2012

SUBJECT: Medicaid Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions

I. General Information

Effective July 1, 2012 Arkansas Medicaid will be implementing 42 CFR 477.26; which requires that all state Medicaid plans prohibit payment for “provider-preventable conditions.” The umbrella term “provider-preventable conditions” (PPCs) includes two separate categories: “healthcare-acquired conditions” (HCACs) and “other provider-preventable conditions” (OPPC). HCACs apply to Medicaid inpatient hospital settings and are generally defined to include the full list of Medicare’s previous inpatient “hospital-acquired conditions” (HAC). Other provider preventable conditions that Arkansas Medicaid will be prohibiting payment for in any healthcare setting will be wrong surgical or other invasive procedure performed on a patient, surgical or other invasive procedure performed on the wrong body part or surgical or other invasive procedure performed on the wrong patient (See table below for detailed descriptions of health acquired conditions and other provider preventable conditions).

To be reportable the adverse event must meet the following criteria:

The event must be reasonably preventable as determined by a root cause analysis.
The event must be within the control of the hospital.
The event must be clearly a result of a preventable mistake made from hospital procedures not being followed; otherwise the event would not have occurred.
The error or event resulted in significant harm which resulted in increased duration and/or complexity of care that is well beyond the norm for treatment of the presenting condition.
All processes for indentifying an event as non-payable will incorporate some element of case-by-case review and determination.
Pursuant to these guidelines providers will not seek payments for additional days or services directly resulting from adverse events.

Health Acquired Conditions: Inpatient Hospital Setting
Air Embolism	Vascular Catheter-Associated Infection
Blood Incompatibility	Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Nonketotic Hypersmolar Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity
Stage III and IV Pressure Ulcers	Surgical Site Infection Orthopedic Procedures Spine Neck Shoulder Elbow Coronary Artery Bypass Graft-Mediastinitis Bariatric Surgery Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery
Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock	Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) Following Total Knee Replacement or Hip Replacement-with pediatric and obstetric exceptions
Catheter-Associated Urinary Tract Infection (UTI)	Provider Preventable Conditions In any Health Care Setting : 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 Unintended retention of a foreign object

II. Reporting an Adverse Health Event

Providers must use Form DMS-2704 Adverse Events Notification to report an Adverse Health Event. Adverse events must be reported to Arkansas Medicaid by faxing a completed Form DMS-2704 to the Division of Medical Services Reimbursement Unit at 501-682-3889. Reports will require the beneficiary first and last name, beneficiary date of birth, beneficiary ID number, type of event, date of event, facility name and contact information. (See form DMS-2704 on the Arkansas Medicaid website and also attached to this Official Notice).

III. Prohibiting Payments for Adverse Events.

Arkansas Medicaid will continue to prohibit payment for events defined as preventable, serious adverse events that occurred under the care of the provider and that are included on the National Quality Forum’s list of Serious Reportable Events as of December 15, 2008. Hospitals and ambulatory surgical centers must utilize the billing system and appropriate diagnosis codes to report conditions present on admission or provider-preventable conditions that occurred during the course of treatment. The State will determine, on a post payment basis, whether to partially or fully recoup claims payment for Health Acquired Conditions (HACs) or Provider Preventable Conditions.

IV. Appeals Processes

Existing appeal processes are available for providers to contest whether the State has improperly identified the occurrence of a condition identified as a Provider Preventable Condition

If you have questions regarding this notice, please contact the HP Enterprise Services Provider Assistance Center at 1-800-457-4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-6453 (Local); 1-800-482-5850, extension 2-6453 (Toll-Free) or to obtain access to these numbers through voice relay, 1-800-877-8973 (TTY Hearing Impaired).

Arkansas Medicaid provider manuals (including update transmittals), official notices, notices of rule making and remittance advice (RA) messages are available for download from the Arkansas Medicaid website: medicaid.mmis.arkansas.gov.

Thank you for your participation in the Arkansas Medicaid Program.

OFFICIAL NOTICE ON00612 PAGE 3 OF 3 DIVISION OF ______________________________________________________
Andrew Allison, PhD

Director

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