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Adverse Medical Events


Provider Administrative Policy

Section
Hospital
Policy Date
January 2009
Status/Date
Revised/June 2011
Provider Type(s)
Hospitals  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Adverse Medical Events

Background
Blue Cross of Idaho developed this reimbursement policy to define, identify and reduce adverse medical events, support other Blue Cross of Idaho quality initiatives and improve hospital reporting.

Definitions
Adverse Medical Event – An adverse medical event is a preventable condition or serious medical event not present when the hospital admits a patient (either inpatient or outpatient) but occurs during the patient`s course of stay and the event or condition was reasonably preventable.  An adverse medical event includes, but is not limited to, any hospital acquired condition identified and adopted, prior to the patient`s admission, by the Centers for Medicare and Medicaid Services (CMS) through administrative rule or regulation.

Present On Admission - Present On Admission (POA) is a patient condition that is present at the time a hospital admits a patient.

Policy
All contracting hospitals must follow the specific coding requirements established by CMS to identify and report an adverse medical event.  If we determine there were additional charges or days at the hospital because of an adverse medical event, there may be a reduction in reimbursement to the hospital. 

Hospitals shall not seek payment from Blue Cross of Idaho, or the patient, for any reductions in reimbursement for services related to an adverse medical event.  However, if another provider is called upon to correct a condition caused by an adverse medical event, then Blue Cross of Idaho may compensate that provider.

Procedure
Blue Cross of Idaho will review all case referrals for an adverse medical event. If the hospital disagrees with the determination, the hospital may submit an appeal in accordance with the Blue Cross of Idaho provider administrative policies available at bcidaho.com.

Blue Cross of Idaho will not reduce reimbursement for an adverse medical event, if the adverse medical event did not occur in the hospital submitting the claim.

Effective January 1, 2009, Blue Cross of Idaho requires all hospitals, including the following, to submit claims with a POA indicator:

  • Acute General Hospitals,
  • Community Hospital,
  • Critical Access Hospitals,
  • Specialty Hospitals,
  • Any facility which Blue Cross of Idaho reimbursement is based upon MS-DRGS.

Use the following POA indicators on the hospital`s UB-04 form (or the subsequent replacement form):

Y     Present at the time of inpatient admission
N     Not present at the time of admission
U     Documentation is insufficient to determine if condition is present on admission
W    Unable to clinically determine whether condition was present at admission or not
1      Exempt from POA reporting, equivalent code of a blank on the UB-04


Policy History

Date Action Reason
June 2011 Revised Added hospital clarification
February 2010 Revised Language added, paragraph 2 under Policy

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