Starting July 1, 2012, federal law requires that all providers report provider-preventable conditions (PPCs) that occur during treatment of Medi-Cal patients. Providers need to report all PPCs that are associated with claims for Medi-Cal payment or with courses of treatment given to a Medi-Cal patient for which payment would otherwise be available. Providers do not need to report PPCs that existed prior to the provider initiating treatment for the beneficiary. For beneficiaries enrolled in Fee-for-Service Medi-Cal, providers report directly to the Department of Health Care Services (DHCS). For beneficiaries enrolled in managed care, providers are to report to the Managed Care Plan. DHCS will provide additional information on reporting requirements for managed care once guidance is received from the Centers for Medicare and Medicaid Services (CMS).
To report to Fee-for-Service Medi-Cal, use the one-page PPC reporting form (DHCS 7107) to report PPCs to DHCS within five working days of discovery of the PPC and confirmation that the patient is a Medi-Cal beneficiary. The form includes a description of PPCs. For beneficiaries enrolled in a managed care plan, providers must report to the beneficiary's plan.
Please note that reporting PPCs for a Medi-Cal beneficiary does not preclude the reporting of adverse events and healthcare-associated infections (HAI) to the California Department of Public Health pursuant to Health and Safety Code.
The federal Affordable Care Act section 2702 and Title 42 of the Code of Federal Regulations, sections 447, 434 and 438 also require that Medi-Cal not pay providers for treatment of PPCs. DHCS will investigate all reports of PPCs, including those it discovers through any means, to determine if payment adjustment is necessary. Interested providers may read the State Plan Amendment for PPCs, which took effect July 1, 2012.
Federal regulations define PPCs. They include health care-acquired conditions (HCAC) in acute inpatient hospital settings only and other provider-preventable conditions (OPPC). The three current OPPCs that CMS requires are to be reported in all health care settings. By law, providers must report any PPC that did not exist prior to the provider initiating treatment for that patient.
CMS added two new HCACs in August 2012 that need to be reported effective October 1, 2012. They are surgical site infection following cardiac implantable electronic device (CIED) procedures and iatrogenic pneumothorax with venous catheterization. CMS added them as hospital-acquired conditions (HACs) with the August 31, 2012 Federal Register (item (II)(F)(5(b)). By federal regulations, HACs automatically become Medicaid HCACs for PPCs. Providers must report these new HCACs that occur on or after October 1, 2012.
HCACs are defined as:
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection (UTI)
• Falls and trauma that result in fractures, dislocations, intracranial injuries, crushing injuries, burns and electric shock
• Foreign object retained after surgery
• Iatrogenic pneumothorax with venous catheterization (October 1, 2012)
• Manifestations of poor glycemic control
o Diabetic ketoacidosis
o Nonketotic hyperosmolar coma
o Hypoglycemic coma
o Secondary diabetes with ketoacidosis
o Secondary diabetes with hyperosmolarity
• Stage III and IV pressure ulcers
• Surgical site infection following:
o Mediastinitis following coronary artery bypass graft (CABG)
o Bariatric surgery, including laparoscopic gastric bypass, gastroenterostomy and laparoscopic gastric restrictive surgery
o Orthopedic procedures for spine, neck, shoulder, and elbow
o Cardiac implantable electronic device (CIED) procedures (October 1, 2012)
• Vascular catheter-associated infection
• For non-pediatric/obstetric population, deep vein thrombosis (DVT)/ pulmonary embolism (PE) resulting from:
o Total knee replacement
o Hip replacement
OPPCs are defined as:
· Wrong surgical or other invasive procedure performed on a patient
· Surgical or other invasive procedure performed on the wrong body part
· Surgical or other invasive procedure performed on the wrong patient
Frequently Asked Questions about PPCs.
PowerPoint presentation from the PPC stakeholder webinar held October 10, 2012.
Providers may email questions about PPCs to PPCHCAC@dhcs.ca.gov.