PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: January 1, 2010.
Purpose: The rule implements new policy pertaining to the department's payment or denial of payment for hospital claims that involve adverse events, hospital-acquired conditions, and/or present on admission indicators, and tells hospital providers the conditions under which the department will not pay for, or only make partial payments for these claims. The rule provides a strong incentive for hospitals to make a correct diagnosis of symptoms upon admission (or as soon thereafter), exercise precautions to avoid unnecessary surgical procedures, reduce hospital-acquired conditions, and improve the quality of care medical assistance clients receive in hospitals. In addition, the new section is consistent with the guidelines set by the Centers for Medicare and Medicaid Services (CMS) for medicare payment reforms that support adjusting payments to hospitals based on quality and efficiency of care.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.
Other Authority: Centers for Medicare and Medicaid Services (CMS).
Adopted under notice filed as WSR 09-17-103 on August 18, 2009.
Changes Other than Editing from Proposed to Adopted Version: (Strikes represent deleted text; underlines
represent new text.)
WAC 388-550-1650 Serious aAdverse events,
hospital-acquired conditions, and present on admission
indicators.
(1)(a) Inpatient hospital claims with ... on and after
November 1, 2009 January 1, 2010;
(c) Serious aAdverse events, ...
(d) Hospital requirements to report serious adverse
events and HACs to the department (see subsection (4)(a) of
this section);
(f) Hospital requirements to use POA indicator codes on
claims (see subsection (4)(g) (5)(a) of this section).
(2)(a) "Serious aAdverse events" (also known as "adverse
health events," "adverse events," or "never events" ... These
serious reportable events are clearly identifiable ... and
serious in their consequences for patients, and of a nature
such that the risk of occurrence is significantly frequently
their occurrence is influenced by the policies and procedures
of the healthcare organization. Some "hospital-acquired
conditions (HACs) can become a serious adverse event if the
(i) Patient dies or is seriously disabled; or (ii) Level of
severity is great, such as the patient develops level 3 or 4
pressure ulcers.
(b) "Hospital-acquired condition (HAC)" is a condition
... after admission. HACs are identified by the U.S. Secretary
of Health and Human Services per Section 5001(c) of the
Deficit Reduction Act (DRA) of 2005 (42 U.S.C. §
1395ww(d)(4)(D)) and the medicare hospital-acquired condition
policy
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acuired_Conditions.asp#TopOfPage) For medicaid payment purposes, HACs are
conditions that the department considers a HAC to be a
condition that (i) Are Is high ... cost or high volume, or both;
(ii) Results in the assignment of a case ... as a secondary
diagnosis; and (iii) Could reasonable [reasonably] have been
prevented through the application of evidence-based
guidelines.; and (iv) Does not conflict with medicare's
hospital-acquired conditions policy
(http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage).
(3)(b) If medicare denies payment for a claim ... for a an
serious adverse health event:
(4) Inpatient hospital claims related to adverse events ... excludes medicare ...
(a) When the department requires information from a
hospital regarding serious adverse events that the hospital
reported to identified by DOH, the hospital ... If no medical
assistance client was affected by a an serious adverse event,
the ...
(b) The department does not pay for serious adverse
events reported to identified by DOH and/or by the hospital or
identified through the department's retrospective utilization
review process (see (a) of this subsection). Some HACs can
become an adverse event if the:
(i) Patient dies or is seriously disabled; or
(ii) Level [of] severity is great, such as the patient develops level three or level four pressure ulcers.
(d) A hospital may request ... to determine if the hospital
is eligible for a partial payment of a for the serious adverse
event should be only partially denied.
(e) A hospital that requests ... review of a an serious
adverse event ... of the serious adverse claim.
(f) The healthcare information ... analysis of the serious
adverse event claim,
(g) is struck and is now part of (5)(a): (g) All
hospitals that have signed a core provider agreement with the
department must provide information to the department by using
POA indicator codes on each claim (refer to the table in this
subsection). These POA indicator codes must designate which
procedures or complications were present on admission, and
which occurred during, or as a result of, hospital care. POA
indicator codes are to be assigned to principal and secondary
diagnosis (as defined in Section II of the Official Guidelines
for Coding and Reporting), and the external cause of injury
codes.
(5) Inpatient hospital claims related to hospital-acquired conditions that do not qualify as an adverse event (excludes medicare crossover inpatient hospital claims discussed in subsection (3) of this section). The department applies the following rules for these claims;
(a) The department reviews POA indicator codes on inpatient hospital claims in order to determine if a condition was present or incubating at the time the order for inpatient admission occurred, if a condition occurred during, or as a result of, hospital care, or if a condition developed during an outpatient encounter.
(i) All hospitals that have signed a core provider agreement with the department must provide information to the department by using POA indicator codes on each claim (refer to the table in this subsection).
(ii) These POA indicator codes must designate which procedures or complications were present on admission, and which occurred during, or as a result of, hospital care.
(iii) POA indicator codes are to be assigned to principal and secondary diagnosis (as defined in Section II of the Official Guidelines for Coding and Reporting), and the external cause of injury codes.
(5) (b)[(b)] The department does not make additional
payments for services in inpatient hospital claims that are
attributable to HACs and are coded with POA indicator codes
"N" or "U." Specifically, for hospitals paid under the:
(i) Diagnositc [Diagnostic] related group (DRG) payment
method, the department Ddoes not make additional payment for
complications and comorbidities (CC) and major complications
and comorbidities (MCC) that are coded with POA indicator
codes "N" or "U" if the claim meets the definition of an HAC.
(ii) Denies payment for any HAC that results in death or
serious disability. Per diem payment method, the department
does not pay for days beyond the average length-of-stay (LOS)
(defined in WAC 388-550-1050).
(iii) Departmental weighted costs-to-charges (DWCC) payment method, the department does not pay for services attributable to the HAC.
(iv) DRG and per diem outlier payment methods, the department does not pay for services attributable to the HAC.
(v) Ratio of costs-to-charges (RCC) payment method, the department does not pay for services attributable to the HAC.
(vi) Per case payment method, the department does not pay for services attributable to the HAC.
(ii) (6) The department Ddenies payment for any HAC that
results in death or serious disability.
(6) (7) A hospital that disagrees with a ... or partial
payment of a an serious adverse event ...
A final cost-benefit analysis is available by contacting Carolyn Adams, P.O. Box 45510, Olympia, WA 98504-5504, phone (360) 725-1854, fax (360) 753-9152, e-mail adamscr@dshs.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 0.
Date Adopted: November 25, 2009.
Susan N. Dreyfus
Secretary
4135.4(a) Inpatient hospital claims with dates of admission on and after January 1, 2010;
(b) Payment or denial of payment for any inpatient hospital claims identified in (a) of this subsection, including medicaid supplemental or enhanced payments and medicaid disproportionate share hospital (DSH) payments or denial of payment;
(c) Adverse events, hospital-acquired conditions (HACs), and present on admission (POA) indicators (defined in subsection (2) of this section);
(d) Hospital requirements to report adverse events and HACs to the department (see subsection (4)(a) of this section);
(e) Hospital requests for retrospective utilization reviews and the related requirements to provide root cause analysis of events to the department (see subsection (4)(d) through (f) of this section); and
(f) Hospital requirements to use POA indicator codes on claims (see subsection (5)(a) of this section).
(2) The following definitions apply to this section:
(a) "Adverse events" (also known as "adverse health events" or "never events") are the events that must be reported to the department of health (DOH) under WAC 246-320-146. These serious reportable events are clearly identifiable, preventable, and serious in their consequences for patients, and frequently their occurrence is influenced by the policies and procedures of the healthcare organization.
(b) "Hospital-acquired condition (HAC)" is a condition that is reasonably preventable and was not present or identifiable at hospital admission but is either present at discharge or documented after admission. For medicaid payment purposes, the department considers a HAC to be a condition that:
(i) Is high cost or high volume, or both;
(ii) Results in the assignment of a case to a diagnosis related group (DRG) that has a higher payment when present as a secondary diagnosis;
(iii) Could reasonably have been prevented through the application of evidence-based guidelines; and
(iv) Does not conflict with medicare's hospital-acquired conditions policy (http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage).
(c) "Serious disability" means a physical or mental impairment that substantially limits the major life activities of a patient.
(d) "Present on admission (POA) indicator" is a status code the hospital uses on an inpatient hospital claim that indicates if a condition was present or incubating at the time the order for inpatient admission occurs. A POA indicator can also identify a condition that develops during an outpatient encounter. (Outpatient encounters include, but are not limited to, emergency department visits, diagnosis testing, observation, and outpatient surgery.)
(e) "Root cause analysis" is a class of problem-solving methods aimed at identifying the root causes of events instead of addressing the immediate, obvious symptoms.
(3) Medicare crossover inpatient hospital claims. The department applies the following rules for these claims:
(a) If medicare denies payment for a claim at a higher rate for the increased costs of care under its HAC and/or POA indicator policies:
(i) The department limits payment to the maximum allowed by medicare;
(ii) The department does not pay for care considered nonallowable by medicare; and
(iii) The client cannot be held liable for payment.
(b) If medicare denies payment for a claim under its National Coverage Determination authority from Section 1862 (a)(1)(A) of the Social Security Act (42 U.S.C. 1395) for an adverse health event:
(i) The department does not pay the claim, any medicare deductible, and/or any co-insurance related to the inpatient hospital services; and
(ii) The client cannot be held liable for payment.
(4) Inpatient hospital claims related to adverse events (excludes medicare crossover inpatient hospital claims discussed in subsection (3) of this section). The department applies the following rules for these claims:
(a) When the department requests information from a hospital regarding adverse events identified by DOH, the hospital must provide the information requested for any affected medical assistance client (this includes both fee-for-service clients and clients enrolled in a managed care organization (MCO) contracted with the department). If no medical assistance client was affected by an adverse event, the hospital must provide a written response to the department with an assurance that no medical assistance clients were affected.
(b) The department does not pay for adverse events identified by DOH and/or identified through the department's retrospective utilization review process. Some HACs can become an adverse event if the:
(i) Patient dies or is seriously disabled; or
(ii) Level of severity is great, such as the patient develops level three or level four pressure ulcers.
(c) The client cannot be held liable for payment.
(d) A hospital may request a retrospective utilization review by the department, as described in WAC 388-550-1700 (6) (a) and (b) (iii), from the department or its designee to determine if the hospital is eligible for a partial payment for the adverse event.
(e) A hospital that requests a department retrospective utilization review of an adverse event must provide the department with the hospital's root cause analysis, as described in WAC 246-320-146 (3) and (4), of the adverse event claim.
(f) The healthcare information that is part of the retrospective utilization review, including the root cause analysis of the adverse event claim, is exempt from public disclosure under RCW 42.56.360 (1)(c).
(5) Inpatient hospital claims related to hospital-acquired conditions that do not qualify as an adverse event (excludes medicare crossover inpatient hospital claims discussed in subsection (3) of this section). The department applies the following rules for these claims:
(a) The department reviews POA indicator codes on inpatient hospital claims in order to determine if a condition was present or incubating at the time the order for inpatient admission occurred, if a condition occurred during, or as a result of, hospital care, or if a condition developed during an outpatient encounter.
(i) All hospitals that have signed a core provider agreement with the department must provide information to the department by using POA indicator codes on each claim (refer to the table in this subsection).
(ii) These POA indicator codes must designate which procedures or complications were present on admission, and which occurred during, or as a result of, hospital care.
(iii) POA indicator codes are to be assigned to principal and secondary diagnosis (as defined in Section II of the Official Guidelines for Coding and Reporting), and the external cause of injury codes.
| POA Indicator Codes | |
| Code | Reason for Code |
| Y | Diagnosis was present at time of inpatient admission. |
| N | Diagnosis was not present at time of inpatient admission. |
| U | Documentation insufficient to determine if condition was present at the time of inpatient admission. |
| W | Clinically undetermined. Provider unable to clinically determine whether or not the condition was present at the time of inpatient admission. |
(i) Diagnostic related group (DRG) payment method, the department does not make additional payments for complications and comorbidities (CC) and major complications and comorbidities (MCC).
(ii) Per diem payment method, the department does not pay for days beyond the average length-of-stay (LOS) (defined in WAC 388-550-1050).
(iii) Departmental weighted costs-to-charges (DWCC) payment method, the department does not pay for services attributable to the HAC.
(iv) DRG and per diem outlier payment methods, the department does not pay for services attributable to the HAC.
(v) Ratio of costs-to-charges (RCC) payment method, the department does not pay for services attributable to the HAC.
(vi) Per case payment method, the department does not pay for services attributable to the HAC.
(6) The department denies payment for any HAC that results in death or serious disability.
(7) A hospital that disagrees with a department decision to deny payment or partial payment of an adverse event or hospital-acquired condition may follow the administrative appeal process in WAC 388-502-0220.
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