Important News

Back to Index

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?

    No

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)
(ICD-9-CM Codes)
Foreign object retained after surgery 998.4 (CC)
998.7 (CC)
Air embolism 999.1 (MCC)
Blood incompatibility 999.6 (CC)
Pressure ulcer stages III and IV 707.23 (MCC)
707.24 (MCC)
Fall and Trauma:
  • Fracture
  • Dislocation
  • Intracranial injury
  • Crushing injury
  • Burn
  • Electric shock
Codes within these ranges on the CC/MCC list:
800-829
830-839
850-854
925-929
940-949
991-994
Catheter-associated urinary tract infection (UTI) 996.64 (CC)
Also excludes the following from acting as a CC/MCC:
112.2 (CC)
590.10 (CC)
590.11 (MCC)
590.2 (MCC)
590.3 (CC)
590.80 (CC)
590.81 (CC)
595.0 (CC)
597.0 (CC)
599.0 (CC)
Vascular catheter-associated infection
Manifestations of poor glycemic control
  • Diabetes ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
999.31 (CC)
250.10-250.13 (MCC)
250.20-250.23 (MCC)
251.0 (CC)
249.10-249.11 (MCC)
249.20-249.21 (MCC)
Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)  
Surgical site infection following certain orthopedic procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
 
Surgical site infection following bariatric surgery for obesity
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery
 
Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures
  • Total knee replacement
  • Hip replacement
 
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