Provider-Preventable Conditions – Definitions
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Ano ang kinakailangan ng provider-preventable conditions (PPCs)?
Ang Title 42 ng Code of Federal Regulations, mga seksyon 447, 434 at 438 at Welfare and Institutions Code (WIC) section 14131.11 ay nangangailangan na ang mga provider ay mag-ulat ng lahat ng PPC na nauugnay sa mga claim para sa Medicaid (Medi-Cal sa California) na pagbabayad o sa mga kurso ng paggamot na ibinibigay sa isang Medicaid na pasyente kung saan ay magagamit ang bayad sa Medicaid. Ang mga pederal na regulasyon at batas ng estado ay nagbabawal din sa Medicaid na magbayad para sa paggamot sa mga PPC.
Ano ang isang PPC?
Mayroong dalawang uri ng mga PPC: health care-acquired conditions (HCAC), na dapat iulat kung nangyari ito sa isang inpatient acute care hospital, at iba pang provider-preventable condition (OPPC), na dapat iulat kung mangyari ito sa anumang setting ng pangangalagang pangkalusugan.
Ano ang mga HCAC?
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.
Mga HCAC:
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Deep vein thrombosis/pulmonary embolism (hindi kasama ang mga buntis at batang wala pang 21 taong gulang)
• Falls/trauma
o Dislocation
o Dislocation
o Intracranial injury
o Crushing injury
o Burn
o Electric shock
• Banyagang bagay na napanatili pagkatapos ng operasyon
• Iatrogenic pneumothorax na may venous catheterization
• Manipestasyon ng mahinang kontrol ng glycemic
o Non-diabetic keto-acidosis
o Hypoglycemic coma
o Pangalawang diabetes na may ketoacidosis
o Pangalawang diyabetis na may hyperosmolarity
• Stage III o IV pressure ulcers
• Surgical site infection
o Mediastinitis kasunod ng coronary artery bypass graft (CABG)
o Surgical site infection na sinusundan ng: Surgical site infection
o Surgical site infection
• Laparoscopic gastric bypass
• Gastroenterostomy
• Laparoscopic gastric restrict surgery
• Orthopedic procedure para sa gulugod, leeg, balikat, at elbow
o Cardiac implantable electronic device (CIED) procedure
• Vascular catheter
Ano ang mga OPPC?
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.