Provider Preventable Conditions (PPC)
| Date: | November 8, 2022 |
| To: | HPSJ Practitioners, Providers and Facilities |
| From: | Health Plan of San Joaquin (HPSJ) |
| Subject: | Provider Preventable Conditions (PPC) |
| Business: | Medi-Cal Managed Care |
Provider Preventable Conditions (PPC) Reminder
Under Section 2702 of the Patient Protection and Affordable Care Act (Pub. L. 111-148) and federal regulations at 42 CFR 447.26, Medi-Cal providers must report “provider preventable conditions” (PPCs) to Medi-Cal agencies; and Medi-Cal agencies are prohibited from paying providers for PPCs in violation of the federal requirements.
A Provider Preventable Condition is a condition that meets the definition of a “Health Care Acquired Condition (HAC)”, or an “Other Provider Preventable Condition (OPPC)” as defined by the Centers for Medicare & Medicaid Services (CMS) in federal regulations at 42 CFR 447.26(b). Please visit the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond for further definition and related diagnosis.
Note: The list of HAC and associated ICD-10 CM & PCS codes are subject to change by CMS and should be reviewed on an annual basis.
Page two provides HPSJ billing guidance that inpatient hospital providers must follow for reporting and billing PPCs.
All inpatient hospital claims related to a PPC must contain the appropriate Present on Admission (POA) indicator.
| POA Value on UB04/837I | Description |
| Y | Diagnosis was present at time of inpatient admission |
| N | Diagnosis was NOT present at the time of admission |
| U | Documentation is insufficient to determine if the condition was present at the time of inpatient admission |
| W | Clinically undetermined. The provider was unable to clinically determine whether the condition was present at the time of inpatient admission. |
The POA indicator is entered on the UB04 form in the shaded portion of boxes 67 and 67a, to the right of the diagnosis field, to indicate when the condition occurred. Additional billing guidance for UB04/Institutional claim form is in the HPSJ Provider Manual Section 10: Claim Submission. https://www.hpsj.com/provider-manual/
If the POA indicator is N or U with respect to a PPC, inpatient hospitals must follow the below reporting guidelines set forth by DHCS:
As of April 3, 2017, the Department of Health Care Services (DHCS) replaced paper form DHCS 7107 with online reporting of PPCs for Medi-Cal and as of July 1, 2017, DHCS no longer accepts paper forms. Please visit the DHCS website for further instructions for online reporting. https://www.dhcs.ca.gov/individuals/Pages/PPC_Form_Instructions.aspx
If you have questions or need assistance, please call our Provider Services team at (209) 942-6340. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.