GENERAL NEWS
Billing Requirements for Provider Preventable Conditions (PPCs) and Hospital-Acquired Conditions (HACs)
As part of our commitment to compliance and accurate reporting, we would like to remind providers of the billing requirements for Provider Preventable Conditions (PPCs) and Hospital-Acquired Conditions (HACs).
Federal and state regulations require providers to bill for PPCs and HACs when they occur, even though these services are not reimbursable. This process ensures transparency, proper documentation, and adherence to quality and compliance standards.
KEY POINTS TO REMEMBER
- Present on Admission (POA) indicators must be accurately reported for both principal and secondary diagnoses in accordance with CMS guidance to correctly identify hospital-acquired conditions (HACs) and provider preventable conditions (PPCs).
- PPC- and HAC-related diagnoses, services, and charges must be reported on claims when they occur during a patient’s stay.
- Claims involving PPCs must identify associated services as non-covered charges.
In accordance with the Utah Medicaid Provider Manual, providers should ensure that all PPC-related diagnoses, services, and charges are submitted as non-covered charges on the claim. These charges are not used in calculating hospital reimbursement. - On UB-04 claims, non-covered charges must be reported for each applicable line item (Form Locator 48 or Loop 2400 SV2) when a PPC is present.
- These conditions do not result in additional payment; reimbursement is adjusted according to CMS and state guidelines.
- Accurate and timely reporting supports quality improvement initiatives and regulatory compliance.
WHY THIS MATTERS
Billing for PPCs and HACs—even without reimbursement—helps maintain the integrity of the healthcare system, supports patient safety programs, and ensures compliance with federal and state requirements.
RESOURCES
If you have questions about this requirement or need assistance with claim submission, please contact us at providers@healthchoiceutah.com. Thank you for your continued partnership in delivering safe, high-quality care.