La. Admin. Code tit. 50 § V-109

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-109 - Healthcare-Acquired and Provider Preventable Conditions

A. Effective for dates of service on or after July 1, 2012, the Medicaid Program will not provide reimbursement for healthcare-acquired or provider preventable conditions which result in medical procedures performed in error and have a serious, adverse impact to the health of the Medicaid recipient.

B. Reimbursement shall not be provided for the following healthcare-acquired conditions (for any inpatient hospital settings participating in the Medicaid Program) including:

1. foreign object retained after surgery;

2. air embolism;

3. blood incompatibility;

4. stage III and IV pressure ulcers;

5. falls and trauma, including:

a. fractures;

b. dislocations;

c. intracranial injuries;

d. crushing injuries;

e. burns; or

f. electric shock;

6. catheter-associated urinary tract infection (UTI);

7. vascular catheter-associated infection;

8. manifestations of poor clycemic control, including:

a. iabetic ketoacidosis;

b. nonketotic hyperosmolar coma;

c. hypoglycemic coma;

d. secondary siabetes with ketoacidosis; or

e. secondary diabetes with hyperosmolarity;

9. surgical site infection following:

a. coronary artery bypass graft (CABG)-mediastinitis;

b. bariatric surgery, including:

i. laparoscopic gastric bypass;

ii. gastroenterostomy; or

iii. laparoscopic gastric restrictive surgery; or

c. orthopedic procedures, including:

i. spine;

ii. neck;

iii. shoulder; or

iv. elbow; or

10. deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement or hip replacement with pediatric and obstetric exceptions.

C. Reimbursement shall not be provided for the following provider preventable conditions, (for any inpatient hospital settings participating in the Medicaid Program) including:

1. wrong surgical or other invasive procedure performed on a patient;

2. surgical or other invasive procedure performed on the wrong body part; or

3. surgical or other invasive procedure performed on the wrong patient.

D. For discharges on or after July 1, 2012, all hospitals are required to bill the appropriate present-on-admission (POA) indicator for each diagnosis code billed. All claims with a POA indicator with a health care-acquired condition code will be denied payment.

La. Admin. Code tit. 50, § V-109

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:1963 (August 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.