​​Provider-Preventable Conditions - Definitions

Title 42 of the ​Code of Federal Regulations, sections 447, 434 and 438 and Welfare and Institutions Code (WIC) section 14131.11 requires that providers report all PPCs that are associated with claims for Medicaid (Medi-Cal in California) payment or with courses of treatment furnished to a Medicaid patient for which Medicaid payment would otherwise be available. Federal regulations and state law also prohibit Medicaid from paying for treatment of PPCs.

There are two types of PPCs: health care-acquired conditions (HCAC), which should be reported if these occur in an inpatient acute care hospital, and other provider-preventable conditions (OPPC), which should be reported if these occur in any health care setting.

HCACs are the same conditions as the hospital-acquired conditions (HACs) that are reportable for Medicare, with the exception that Medi-Cal does not require providers to report deep vein thrombosis/pulmonary embolism for pregnant women and children under 21 years of age, as noted below.

The ICD-10-CM codes for HCACs are available on the CMS website for "ICD-10 HAC List."

Providers need to report HCACs only when they occur in inpatient acute care hospitals.

HCACs:
　•　Air embolism
　•　Blood incompatibility
　•　Catheter-associated urinary tract infection
　•　Deep vein thrombosis/pulmonary embolism (excluding pregnant women and children under 21 years of age )
　•　Falls/trauma that result in the following:
　　  o　Fracture
　 　 o　Dislocation
　 　 o　Intracranial injury
　 　 o　Crushing injury
　 　 o　Burn
　 　 o　Electric shock
　•　Foreign object retained after surgery
　•　Iatrogenic pneumothorax with venous catheterization
　•　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 or IV pressure ulcers
　•　Surgical site infection
　 　 o　Mediastinitis following coronary artery bypass graft (CABG)
　 　 o　Surgical site infections following:
　　 　　　 •　Bariatric surgery
　　　　　　 　　 •　Laparoscopic gastric bypass
　　　　　　 　　 •　Gastroenterostomy
　　　　　 　　　 •　Laparoscopic gastric restrict surgery
　　 　　 •　Orthopedic procedures for spine, neck, shoulder, and elbow
　　  o　Cardiac implantable electronic device (CIED) procedures
　•　Vascular catheter-associated infection

OPPCs are also known as "never events" and Serious Reportable Events under Medicare. For Medi-Cal, OPPCs are defined as follows:
•　Wrong surgery/invasive procedure
•　Surgery/invasive procedure performed on the wrong patient
•　Surgery/invasive procedure performed on the wrong body part

 

Providers must report these three OPPCs when these occur in any health care setting. "Invasive procedure" refers to a surgical procedure.