Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)

CMS-10398 #32 (OCN 0938-1148)

Expiration date: 10/31/2014

(formerly CMS-10364, OCN 0938-1136)

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Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under

Section 4.19 (A)

X Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

This item is mandatory. States should mark this box to indicate that conditions identified are consistent with, and reimbursement has been amended to deny payment for Health Care- Acquired Conditions as defined at 42 CFR 447.26(b).

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Section(s) 4.19 (Use this space to indicate the appropriate reimbursement section or sections of the plan.)

X 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.

This item is mandatory. States should mark this box to indicate that conditions identified are consistent with, and reimbursement has been amended to deny payment for Other Provider Preventable Conditions as defined at 42 CFR 447.26(b).

X Additional Other Provider-Preventable Conditions identified below (please indicate the section(s) of the plan and specific service type and provider type to which the provisions will be applied. For example – 4.19(d) nursing facility services, 4.19(b) physician services) of the plan:

This item is not mandatory. It should only be marked if the State intends to deny payment for Other provider preventable conditions (OPPCs) not required by the final rule.

An OPPC is a condition that can occur in any health care setting. The rule requires that States must include the “three wrongs” (wrong site, wrong surgery, wrong patient) as part of their non-payment policies under the OPPCs category. Conditions added by the State must have negative consequences for beneficiaries and be auditable.

If the State intends to expand its list of conditions, the State must:

1. revise its Medicaid State plan to identify the condition and the provider type/service setting on this pre-print;

2. revise their Medicaid Reimbursement sections as necessary to indicate how provider payments will be adjusted; and

3. make a finding, based upon a review of medical literature by qualified professionals, that a condition is reasonably preventable through the application of procedures supported by evidence-based guidelines.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 7 hours per response, including the time to complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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