Preventable Adverse Events

Policy No: 106
Originally created: 04/01/2009
Section: Administrative
Last Reviewed: 05/01/2023
Last Revised: 05/01/2023
Approved: 07/11/2024
Effective Date: 08/01/2024
Policy applies to: Group and Individual

This policy applies to all physicians, other health care professionals, hospitals and other facilities.

Adverse Event – An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care. This includes never events; hospital-acquired conditions; events that required life-sustaining intervention; and events that caused prolonged hospital stays, permanent harm, or death  (see Reference #1). This would also include an iatrogenic complication.

Preventable event – A preventable event is an adverse event that could have been prevented through the application of evidence-based guidelines (see Reference #6). If evidence-based guidelines are not available, other resources including but not limited to medical director consensus and/or clinical expertise, aided by using UpToDate, Milliman Care Guidelines (MCG), Centers for Disease Control and Prevention (CDC), National Institute of Health (NIH), National Comprehensive Cancer Network (NCCN) Guidelines, positions of leading national health professional organizations and specialty matched reviews.

Never Event/Sentinel Event/Serious Reportable Event (SRE) – Adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable (see Reference #3). Specific Serious Reportable Events are commonly referred to as “never events” by Centers for Medicare and Medicaid Services (CMS) (see Reference #4).

Hospital Acquired Condition (HAC) – A hospital-acquired condition (HAC) is one of several medical conditions a patient can acquire during a hospital stay that was not present on admission (POA)(see Reference #2). HACs include preventable infections and medical errors. HACs are reported by the hospital or facility through claims submission with the use of a Present on Admission (POA) Indicator.

Iatrogenic Complication – Any adverse conditions which are the direct result of treatment by a physician or other health care professional.

Provider – defined as health system, or by other providers in its health system, or by entity wholly owned or wholly operated by Provider/health system, or by another provider under arrangements with Provider.

Our health plan believes that when a member enters a facility for treatment of a medical problem, the member should not experience a preventable adverse event during the member’s stay. Accordingly, our health plan expects all providers to take proper precautions to ensure a preventable adverse event does not occur.

Our health plan will not reimburse providers for a preventable adverse event. All providers are required to hold members harmless for any services related to preventable adverse events. As part of our health plan’s commitment to improving the quality of care available to members, we have adopted reimbursement policies that encourage providers to reduce the incidence of preventable adverse events.

Examples of preventable adverse events (this list is not all inclusive of indications which may be reviewed in accordance with the reimbursement policy):

• Surgical adverse event that could have reasonably been prevented with a change in surgical technique or clinical judgement
• Certain surgical site infections
• Nosocomial infections (also known as a hospital acquired infection)
• Error in the dose or administration of a drug

Non-reimbursable procedures/services include but are not limited to:

• All adverse event related services provided in the operating room when the initial planned procedure is not completed, are considered not reimbursable.
• All adverse event related services provided during the same or subsequent facility stay/visit are not reimbursable.

• Providers should note that adverse event related services do not include performance of the procedure, i.e. originally planned and completed procedure(s).

When a preventable adverse event occurs, the case will be reimbursed as though the secondary preventable adverse event diagnosis is not present. We will consider reimbursement for services not related to preventable adverse event if itemized statements are submitted with the claim.

Our health plan will consider reimbursement for anticipated preventable adverse events occurring with high-risk non-elective procedures, such as repair of major trauma.

If provider was not the primary provider performing the service causing the preventable adverse event and/or the provider where the preventable adverse event occurred, providers will be reimbursed for costs incurred to treat preventable adverse events.

Our health plan requires diagnosis codes on all provider claims in order to determine if a preventable adverse event occurred, as mandated by official coding guidelines.

The relevant ICD diagnosis code for an ‘external cause of injury code’ is required to be submitted on all applicable claims as the diagnosis in the secondary position to indicate that a preventable adverse event has occurred.

Providers are required to submit a Present on Admission (POA) Indicator on all claims in which a preventable adverse event occurred. POA indicators are assigned to the principal and secondary diagnoses (see Reference #7).

POA Indicator Options and Descriptions (see Reference #7):

• Y = Diagnosis was present at the time of inpatient admission
• N = Diagnosis was not present at the time of inpatient admission
• U = Documentation insufficient to determine if the condition was present at the time of inpatient admission

• W = Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

The following are exempt from the POA indicator (see Reference 15) options above:

• Critical Access Hospitals
• Long Term Care Hospitals
• Maryland Waiver Hospitals
• Cancer Hospitals
• Children’s Inpatient Facilities
• Religious Non-Medical Health Care Institutions
• Inpatient Psychiatric Hospitals
• Inpatient Rehabilitation Facilities

• Veterans Administration/Department of Defense Hospital

Never Event/Sentinel Event/Serious Reportable Event (SRE) (see Reference #4)
include, but are not limited to:

• Surgery performed on the wrong patient
• Surgery performed on the wrong body part

• Wrong surgery performed on a patient (see Reference #14)

Preventable adverse events include (see Reference #6), but not limited to:

• Foreign Object Unintentionally Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma
  • Fractures
  • Dislocations
  • Intracranial Injuries
  • Crushing Injuries
  • Burn
  • Other Injuries
• Manifestations of Poor Glycemic Control
  • Diabetic Ketoacidosis
  • Nonketotic Hyperosmolar Coma
  • Hypoglycemic Coma
  • Secondary Diabetes with Ketoacidosis
  • Secondary Diabetes with Hyperosmolarity
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular-Catheter Associated Infection
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)
• Surgical Site Infection Following Bariatric Surgery for Obesity
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Surgical Site Infection Following Certain Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
  • Total Knee Replacement
  • Hip Replacement

• Iatrogenic Pneumothorax with Venous Catheterization

The Appendix A table below is the Centers for Medicare & Medicaid Services (CMS) Hospital Acquired Conditions list (see Reference #9). This list of hospital acquired conditions is not all inclusive.

1. Spotlight On... Adverse Events (n.d.). from Office of the Inspector General

2. Centers for Medicare & Medicaid Services (CMS), Publicly Reported DRA HAC Measures, Frequently Asked Questions 2022

3. U.S. Deparment of Health and Human Services - Agency for Healthcare Research and Quality (AHRQ), Patient Safey Primer, Never Events

4. Kizer, Stegun, Serious Reportable Adverse Events in Health Care, vol 4, from AHRQ.gov

5. Centers for Medicare & Medicaid Services (CMS) Coverage Decision Memos: NCA Tracking Nos. CAG-00401N, CAG-00402N, CAG-00403N

6. Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions

7. Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator), Coding

8. Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator)

9. Centers for Medicare & Medicaid Services (CMS), Hospital-Acquired Conditions (Present on Admission Indicator), ICD-10 HAC List

10. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Wrong Surgical or Other Invasive Procedure Performed on a Patient (140.6)

11. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Surgical or Other Invasive Procedure Performed on the Wrong Body Part (140.7)

12. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Surgical or Other Invasive Procedure Performed on the Wrong Patient (140.8)

13. Centers for Medicare & Medicaid Services (CMS), ICD-10-CM Official Guidelines for Coding and Reporting

14. Centers for Medicare & Medicaid Services (CMS), Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgery or Other Invasive Procedure Performed on the Wrong Body Part; and Surgical or Other Invasive Procedure Performed on the Wrong Patient – JA6405

15. Centers for Medicare & Medicaid Services (CMS), Affected Hospitals, Hospital-Acquired Conditions (Present on Admission Indicator)

None