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Provider Preventable Conditions

Section 2702 of the Patient Protection and Affordable Care Act of 2010 (The Affordable Care Act) requires the Secretary to issue Medicaid regulations effective July 1, 2011 prohibiting federal payments to states under section 1903 of the Social Security Act for any amounts expended for providing medical assistance for health care-acquired conditions. Specifically, the statute directs the Secretary to identify current state practices that prohibit payment for HCAC and incorporate those practices, as appropriate, into Medicaid policy regulations; ensure that the Medicaid HCAC regulations do not impact beneficiary access to care; define the term "health care-acquired condition" in accordance Medicare's inpatient hospital statutory language at 1886(d)(4)(D)(iv); and apply Medicare's provisions regarding the identifiable hospital acquired condition (HAC) and never events to Medicaid regulations, excluding any condition identified for non-payment under Medicare that may not be applicable to Medicaid.

Final Rule
On June 30, 2011, CMS published a final rule implementing the requirements of Section 2702. The final rule requires that states implement non-payment polices for provider preventable conditions (PPCs) including health care-acquired conditions (HCACs) and other provider-preventable conditions (OPPCs).
The minimum set of conditions, including infections and events, that states must identify for non-payment are:

Category 1 – Health Care-Acquired Conditions (For Any Inpatient Hospitals Settings in Medicaid)

  • Foreign Object Retained After Surgery
  • Air Embolism
  • Blood Incompatibility
  • Stage III and IV Pressure Ulcers
  • Falls and Trauma; including Fractures, Dislocations, Intracranial Injuries , Crushing Injuries, Burns, Electric Shock
  • Catheter-Associated Urinary Tract Infection (UTI)
  • Vascular Catheter-Associated Infection
  • Manifestations of Poor Glycemic Control; including:Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary  Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity
  • Surgical Site Infection Following:
    • Coronary Artery Bypass Graft (CABG) - Mediastinitis
    • Bariatric Surgery; including Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery
    • Orthopedic Procedures; including Spine, Neck, Shoulder, Elbow
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Total Knee Replacement or Hip Replacement with pediatric and obstetric exceptions

Category 2 – Other Provider Preventable Conditions (For 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
  • OPPCs identified in the state's plan and according to the requirements of the final regulation