Hospital Acquired Conditions
and Iatrogenic Complications
| Topic: Hospital
Acquired Conditions and Iatrogenic Complications |
Date
of Origin: April 2009 |
| Section: Administrative |
Policy
No: 106 |
| Last Reviewed Date:
May 2011 |
Last Revised Date:
November 2011 |
This policy applies to all physicians, other health care professionals, hospitals and other facilities.
Description
Hospital Acquired Condition (HAC) - a condition that is not present when the patient is admitted to or arrives at the hospital or other facility, but develops during the stay. HACs include preventable infections and medical errors.
Iatrogenic Complications - any adverse conditions which are the direct result of treatment by a physician or other health care professional.
Never Events – a term used generically to refer to HACs, Iatrogenic Complications and Serious Reportable Events
Serious Reportable Events – events that could have reasonably been prevented through application of evidence-based guidelines. These conditions are not present on admission, or when the patients are treated, but occur during the course of treatment or stay. Examples include, but are not limited to:
- performance of the wrong operation/procedure on a patient
- performance of the right operation/procedure on the wrong side of the body
- performance of an operation/procedure on the wrong patient or any misadventure during medical care, such as unintended retention of a foreign object after surgery, death or serious disability due to hemolytic reaction resulting from blood incompatibility, or infant discharge to wrong person.
Modifiers and diagnosis codes which could indicate a Serious Reportable Event include, but are not limited to:
Centers
for Medicare and Medicaid (CMS) Serious Reportable
Events |
HCPCS
modifiers |
| – PA |
Used when surgery or other invasive procedure is performed on the wrong body part. |
| – PB |
Used when surgery or other invasive procedure is performed on the wrong patient. |
| – PC |
Used when the wrong surgery or other invasive procedure is performed on a patient. |
ICD-9
diagnosis codes |
| E870 to E876 |
Misadventures During Surgical and Medical Care |
| E884.x, E885.9, E888.x |
Falls |
Policy Statement
Physicians, other health care professionals, hospitals and other facilities will not be reimbursed nor allowed to retain reimbursement for costs incurred as a result of Hospital Acquired Conditions, Iatrogenic Complications, Never Events or Serious Reportable Events. The reduction in reimbursement will be calculated using the reimbursement methodologies in place for the provider at the time of service, and could include part or all of an episode of care.
Hospital Acquired Conditions, Iatrogenic Complications, Never Events and Serious Reportable Events will be denied provider write-off.
Physicians, other health care professionals, hospitals and other facilities will be reimbursed for costs incurred to treat an iatrogenic complication if that physician, other health care professional, hospital or other facility was not the primary practitioner performing the service causing the iatrogenic complication and/or the primary hospital or facility where the iatrogenic complication occurred.
Physicians, other health care professionals, hospitals and other facilities are expected to report to Regence all Never Events using the appropriate modifiers and diagnosis codes.
References
CMS Coverage Decision Memos: NCA Tracking Nos. CAG-00401N, CAG-00402N, CAG-00403N
Cross References
None
Your use of this Reimbursement Policy constitutes your agreement to be bound
by and comply with the terms and conditions of the Reimbursement
Policy Disclaimer.
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