Provider Preventable Conditions (PPC)

On May 23,2017, the Department of Healthcare Services (DHCS) released ALL Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC FORM on DHCS secure online portal for both Medicare and Medi-Cal lines of business.

Further  information is available on the following pages:

Medicare and Medi-Cal lines of business must follow the instructions below:

  1. Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS;
  2. IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract.
  3. As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported:

Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid)

  • Any unintended foreign object retained after surgery
  • A clinically significant air embolism
  • An incidence of blood incompatibility
  • A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital
  • A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock
  • A catheter-associated urinary tract infection
  • Vascular catheter-associated infection
  • Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity
  • A surgical site infection following:
    • Coronary artery bypass graft (CABG) - mediastinitis
    • Bariatric surgery; including laparoscopic gastric bypass,gastroenterostomy, laparoscopic gastric restrictive surgery
    • Orthopedic procedures; including spine, neck, shoulder, elbow
    • Cardiac implantable electronic device procedures
  • Deep vein thrombosis/pulmonary embolism following total kneww replacement or hip replacement with pediatric and obstetric exceptions
  • Latrogenic pneumothorax with venous catheterization
  • A vascular catheter-associated infection

Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting)

  • Wrong surgical or other invasive procedure performed on a patient
  • Surgical or other invasive procedure performed on the wrong body part
  • Surgical or other invasive procedure performed on the wrong patient