Performance & Enrollment

New York State Medicaid "Never Events"

Please read important information concerning this new reimbursement policy below:

Effective October 1, 2008, Medicaid will deny or reduce payment for three (3) "Never Events" (object left in after surgery, air embolism, and blood incompatibility)..

This new reimbursement policy applies to discharges on or after October 1, 2008. The New York State Department of Health will suppress the ICD-9 codes relating to these events and make use of the "Present on Admission" indicator to adjust reimbursement accordingly. All inpatient claims (including claims from Article 31 facilities, inpatient substance abuse programs, critical access hospitals, children's hospitals) are required to have a valid Present on Admission (POA) indicator for each diagnosis. Claims that lack a valid POA indicator will be denied. Medicaid will audit the accuracy of this claim field. Medicaid is using POA definitions as outlined by CMS, described in MLN Matters Number 5499, and detailed at: http://cms.hhs.gov/Transmittals/downloads/R1240CP.pdf

To prevent billing Medicaid for charges that may result from the suppression of these diagnosis codes, hospitals are instructed not to bill for day or high cost outlier payments which are a result of, or significantly associated with, the three (3) events mentioned above.

Implementation of payment reductions for the additional eleven (11) events will be deferred until the Department has established one or more specific rate codes, which will be applied by hospitals to all claims (including day or cost outliers) in which one of these eleven events occurred. The Department will then "pend" claims and review for appropriate payment modifications or adjustments.

The Department will provide hospitals with specifics regarding application of the rate code or codes and reimbursement guidelines in advance of implementation. It is expected that implementation for the eleven (11) events will take place in early 2009.

Questions? Please contact John Franklin at (518) 473-8822 or Dr. Foster Gesten at (518) 486-6865.

14 Hospital Acquired Events for New York State Medicaid

  1. Surgery performed on wrong body part
  2. Surgery performed on wrong patient
  3. Wrong surgical procedure on a patient
  4. Retention of a foreign object in a patient after surgery or other procedure
  5. Patient disability associated with a medication error
  6. Patient disability associated with a reaction to administration of ABO-incompatible blood or blood products
  7. Patient disability associated with failure to identify and treat hyperbilirubinemia in neonates
  8. Patient disability associated with use of contaminated drugs, devices, biologics provided by healthcare facility
  9. Patient disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
  10. Patient disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  11. Patient disability associated with an electric shock while being cared for in a health care facility
  12. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by a toxic substance
  13. Patient disability associated with a burn incurred from any source while being cared for in a healthcare facility
  14. Patient disability associated with the use of restraints or bedrails while being cared for in a healthcare facility