Never Events and Hospital Acquired Conditions (HACs)
Effective January 18, 2011, BCBSNC has updated the policy on Hospital Acquired Conditions and Never Events to provide more detailed explanation on the conditions and codes. To read the revised policy, please follow the link to the BCBSNC provider portal for the medical policy - http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/nonpayment_for_serious_adverse_events.pdf.
Please also see the below Questions & Answers, to help answer any questions you may have regarding this new policy.
Frequently Asked Questions
1. Why is BCBSNC making changes to the current corporate medical policy around Serious Adverse Events?
- To better align BCBSNC policies and procedures with CMS guidelines and to meet BCBS Association mandates around uniform handling of claims.
2. When are these changes effective?
- January 18, 2011
3. What are Never Events and Hospital Acquired Conditions (HACs)?
- Never events are adverse events that are serious, largely preventable, and are of concern to both the provider and the public.
- Hospital Acquired Conditions (HACs) is an undesirable situation or condition arising during a time spent in a hospital or medical facility.
4. If a claim has a Never Event code, how will the claim process?
- For dates of service on or after January 18, 2011, the entire claim will be denied for provider payment.
5. If a claim has a HAC code, how will the claim process?
- For dates of service on or after January 18, 2011, the claim will be re- priced without the HAC code to determine appropriate level of payment on any covered and reimbursable charges.
6. Are these payment decisions appealable?
7. How were providers notified around these changes to the current corporate medical policy?
- The new policy was announced on the BCBSNC provider portal for a 90 day review period. BCBSNC staff met with the North Carolina Hospital Association (NCHA) in the fall of 2010.
- Network Management Provider Relations staff have included this topic on monthly agendas with statewide facility providers.
8. Does this policy follow current Medicare guidelines and processes around Serious Adverse events?
- BCBSNC has made every attempt to align our policies and procedures with current Medicare requirements when feasible.
Hospital Acquired Conditions and Codes
Current ICD Diagnosis Code list:
|HAC||Complicating Condition (CC)
Major Complicating Condition (MCC)
|Foreign object retained after surgery||998.4 (CC)
|Air embolism||999.1 (MCC)|
|Blood incompatibility||999.6 (CC)|
|Pressure ulcer stages III and IV||707.23 (MCC)
|Fall and Trauma:
||Codes within these ranges on the CC/MCC list:
|Catheter-associated urinary tract infection (UTI)||996.64 (CC)
Also excludes the following from acting as a CC/MCC:
|Vascular catheter-associated infection
Manifestations of poor glycemic control
|Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)|
|Surgical site infection following certain orthopedic procedures
|Surgical site infection following bariatric surgery for obesity
|Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures
|Never Events||ICD-9-CM Codes|
|Performance of wrong operation on correct patient||E876.5|
|Performance of wrong operation on (procedure) intended for another patient||E876.6|
|Performance of correct operation (procedure) on wrong body part/site||E876.7|