Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix J

Effective July 1, 2012, the Centers for Medicare and Medicaid Services (CMS) directed all state Medicaid

agencies to implement its final rule outlined in 42 CFR 447.26, regarding Provider Preventable Conditions

(PPCs), Never Events (NEs), and Hospital Acquired Conditions (HACs) acquired in all hospital settings and other

non-inpatient health care settings.

HACs are defined as diagnoses determined by either the state and/or Medicare to be reasonably preventable, i.e.,

Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following a total knee replacement or hip replacement

surgery, and PPCs, i.e., the wrong body part and surgical invasive procedures performed by a practitioner or

provider to the wrong patient that should never happen in an admission to treat a medical condition. CMS

specifically in Section 2702 of the Patient Protection and Affordable Care Act, prohibits payment to providers for

Other Provider-Preventable Conditions (OPPPCs) as specified in 42 CFR 434, 438, and 447 of the Federal

Register, page 32816.

The Hospital Services Manual in Section 1102(e) outlines the Department’s policies and procedures on HACs as

identified by Medicare’ federal regulations published in October 2010. The Georgia Medicaid Management

System (GAMMIS) was configured on July 1, 2011 with the HACs edits. The Department of Community Health

will not reimburse inpatient facilities (if applicable) or enrolled Medicaid practitioners/providers for treatment of

any HACs and/or PPCs identified through the claim’s adjudication and/or medical records review process. NEs in

Inpatient Hospitals, Outpatient Hospitals, Ambulatory Surgical Centers (ASC) and practitioners and providers

regardless of the healthcare setting are required to report NEs. Refer to the Reimbursement sections of the

Hospital Services and Physician Services Policies and Procedures Manuals for additional information.

Claims will be subject to retrospective review in accordance with CMS’ directive and the State Plan Amendment,

Appendix 4.19. When a claim’s review indicates an increase of payment to the provider for an identified PPC,

HAC, or NE, the amount for the event or provider preventable condition will be excluded from the provider’s

total payment.

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition

defined as a PPC for a patient existed prior to the initiation of treatment for that patient by that provider. Non-payment of provider-preventable conditions shall not prevent access to services for Medicaid beneficiaries.