Commercial

Medical Policy

Notification

Never Events and Preventable Serious Adverse Events

Notification Issued Date: N/A

This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to the policy:

T81.40XA: Infection following a procedure, unspecified, initial encounter

T81.41XA: Infection following a procedure, superficial incisional surgical site, initial encounter

T81.42XA: Infection following a procedure, deep incisional surgical site, initial encounter

T81.43XA: Infection following a procedure, organ and space surgical site, initial encounter

T81.44XA: Sepsis following a procedure, initial encounter

T81.49XA: Infection following a procedure, other surgical site, initial encounter

This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM code has been termed from the policy:

T81.4XXA: Infection following a procedure, initial encounter

This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM narratives have been revised in this policy:

S62.626B

FROM: Displaced fracture of medial phalanx of right little finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of right little finger, initial encounter for open fracture

S62.627B

FROM: Displaced fracture of medial phalanx of left little finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of left little finger, initial encounter for open fracture

S62.628B

FROM: Displaced fracture of medial phalanx of other finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of other finger, initial encounter for open fracture

S62.629B

FROM: Displaced fracture of medial phalanx of unspecified finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of unspecified finger, initial encounter for open fracture

S62.654B

FROM: Nondisplaced fracture of medial phalanx of right ring finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of right ring finger, initial encounter for open fracture

S62.655B

FROM: Nondisplaced fracture of medial phalanx of left ring finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of left ring finger, initial encounter for open fracture

S62.656B

FROM: Nondisplaced fracture of medial phalanx of right little finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of right little finger, initial encounter for open fracture

S62.657B

FROM: Nondisplaced fracture of medial phalanx of left little finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of left little finger, initial encounter for open fracture

S62.658B

FROM: Nondisplaced fracture of medial phalanx of other finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of other finger, initial encounter for open fracture

S62.659B

FROM: Nondisplaced fracture of medial phalanx of unspecified finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of unspecified finger, initial encounter for open fracture

Policy Attachment

Attachment to Policy #

00.01.44j

Attachment:

Policy #:

00.01.44j

Description:

Pennsylvania House Bill No. 84 addressing Never Events and Preventable Serious Adverse Events

Title:

Never Events and Preventable Serious Adverse Events

SUMMARY: PA STATE MANDATE HOUSE BILL NO. 84

For members enrolled in a PA product:

Pennsylvania House Bill No. 84 (“the Act”) was signed into law by Governor Rendell on June 10, 2009, and prohibits professional providers and facilities from seeking reimbursement for a “preventable serious adverse event.”

General Rule

A health care provider may not seek payment from a payor or patient for a preventable serious adverse event or any services required to correct or treat the problem created by a preventable serious adverse event when that event occurred under the provider’s control.

Refunds

Health care providers who discover that payment was unknowingly requested for a preventable serious adverse event or services required to correct or treat the problem created by such an event, must immediately notify the payor or patient and refund any payment that has been received within 30 days of discovery of the preventable serious adverse event or receipt of payment, whichever is later.

Notification Requirements

If a payor discovers that payment has been sought for a preventable serious adverse event or services required to correct or treat the problem created by such an event, the payor must notify the provider that payment may not be sought for such an event or services and that payment shall not be made for such events or services.

Investigation of Complaints

The Department of Health shall be responsible for investigating complaints from payors and patients regarding facility providers that are seeking payment for a preventable serious adverse event.

The Department of State shall be responsible for investigating complaints from payors and patients regarding non-facility providers who are seeking payment for a preventable serious adverse event.

Publication of Preventable Serious Adverse Events

The Department of Health will publish any updates to the National Quality Forum’s (NQF) list of reportable serious adverse events within 30 days.

The Department of Public Welfare will publish a proposed preventable serious adverse events bulletin for nursing facilities and solicit comments about the preventable serious adverse events. After a 30-day public comment period, the Department of Public Welfare may adopt the preventable serious adverse events bulletin by publication in the Pennsylvania Bulletin.

Liability

Information provided to a payor or provider in compliance with the Act is not discoverable or admissible in any civil or administrative action related to the Medical Care Availability and Reduction of Error Act.

Contracts

The Act does not prohibit a payor and a health care provider from establishing, by contract, polices or procedures necessary to implement the Act.

Definitions

(1) Health care facility
A health care facility as defined under section 802.1 of the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act, or an entity licensed as a hospital under the act of June 13, 1967 (P.L.31, No.21), known as the Public Welfare Code.

(2) Health care provider
A health care facility or a person, including a corporation, university or other educational institution, licensed or approved by the Commonwealth to provide health care or professional medical services. The term shall include, but not be limited to, a physician, a certified nurse midwife, a podiatrist, a certified registered nurse practitioner, a physician assistant, a chiropractor, a hospital, an ambulatory surgery center, a nursing home or a birth center.

(3) Health payor
An individual or entity paying for health services for himself or itself or on behalf of another.

(4) Medical assistance
The Commonwealth's medical assistance program established under the act of June 13, 1967 (P.L.31, No.21), known as the Public Welfare Code.

(5) National Quality Forum (NQF)
A not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting.

(6) Preventable serious adverse event
An event that occurs in a health care facility that is within the health care provider's control to avoid, but that occurs because of an error or other system failure and results in a patient's death, loss of body part, disfigurement, disability or loss of bodily function lasting more than seven days or still present at the time of discharge from a health care facility. The events shall be included on the list of reportable serious adverse events adopted by the National Quality Forum or in a bulletin as provided under this act.

Version Effective Date:

12/05/2022

Version Issued Date:

12/05/2022

Version Reissued Date:

06/26/2024