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Provider Preventable Conditions

Provider Preventable Conditions

Definition

A Provider Preventable Condition (PPC) is defined as "harm experienced by a patient as a result of medical care, or harm that occurs in a medical setting, unrelated to the reason for the patient visit."

Provider Preventable Conditions (PPC) were formerly known as Healthcare Acquired Conditions (HAC). The term Provider Preventable Conditions is sometimes substituted with the terms "Adverse Event", "Never Event", and "Serious Reportable Condition". Though it is presently understood that there are subtle differences in the meanings of these terms, readers will notice that in the past, state and federal documents have used these terms interchangeably.

Who is Responsible for Potentially Preventable Conditions (PPC)

The existence of a PPC is not a statement of blame or culpability. For example, PPC 6 is "Falls/Trauma". Just as an individual can fall and break a hip while walking through the home, the same can occur in a room at a healthcare facility while walking to the restroom. If a patient falls at a medical facility, even if there is no injury, the facility is required to code the incident, and it may be displayed below. The posting of a PPC is not a report on incompetence or carelessness. PPC 2 is "Foreign Body" left in patient. This can mean a surgical sponge or utensil left in a patient after surgery (and this definitely would be an error), but it can also signify a good judgement call by an experienced physician. For example, while a physician is setting and anchoring a compound fracture, a screw may break within the bone. The physician may correctly choose to leave the screw fragment within the patient, as removing it may cause unnecessary trauma. This situation may be coded as a PPC for foreign body left in patient, but is clearly not a sign of incompetence.

Hospitals have 30 days to review each individual case prior to posting. The purpose of these web pages is to show serious events. Facilities may provide extenuating circumstances for a case that can cause its removal. For example, if a patient fell, but there was no injury, and the facility reported this to CHIA, that case will be removed prior to posting. Another example is for "Foreign Body Left in Patient". If this foreign body (such as a screw) was intentionally left in the body for the patients benefit, and CHIA was notified, that PPC would be removed prior to posting.

Purpose of Posting

The purpose of posting these events is to look at the big picture. In any endeavour, including medical care, there is always room for improvement. Although not all PPCs are preventable, a high rate of PPCs may suggest room for improvement. Medical facilities can view this page as an indicator where resources should be applied. This information can assist in the development and enhancement of existing safety policies. When you, the user, view the PPCs, keep in mind that there is not enough information to make a judgement call on a hospital. Some hospitals specialize in difficult cases and may have higher rates of PPCs. Some PPCs are difficult to code, as the attending physician may not have enough information to determine if the PPC occurred at their facility, or if the patient arrived with the condition. Even under these circumstances of missing information, the PPC is still counted and displayed on this website.

Understanding Counts and Rates

You'll notice counts and two rate values are being displayed. If only counts were displayed, large medical facilities would be misrepresented by appearing worse than small facilities. If only rates were displayed, small facilities would be misrepresented, as the addition of a single PPC at a small facility causes a large increase in the rate.

Displaying rates per 1000 discharges is a national norm, but it doesn't present the entire picture. At times a patient may reside at a facility for many days. This could be due to a chronic illness, insurance requirements, or other reasons. Each day a patient remains at a medical facility, that patient has the potential of falling, or getting a bed sore, a catheter infection and so on. Displaying a rate by 1000 bed days compensates for this.

Minimum Cell Size

To protect patient privacy, not all numbers are displayed for all hospitals. Minimum cell size is limited by the denominator, not the numerator. The numerator is the number of PPCs. The denominator is the total number of discharges at a hospital during the year. If the denominator is less than 100, the PPC information is not displayed. The numerator can be as small as 1.

To determine the best minimum denominator size, federal government documents at the CDC and the Federal Committee on Statistical Methodology were studied. It turns out there is no definitive rule. Patricia Sweeney of the CDC, in her presentation "The Balancing Act: Limiting Disclosure vs. Optimizing Data Use", at the 2010 CSTE Pre-Conference Workshop, June 7, 2010, discussed cell size limitations from 5-1000. Based on her reasoning, and the fact that no patient demographics are provided on the PPC web page, the Center for Health Information Analysis, and the State of Nevada, Division of Health Care Financing and Policy settled on 100 as the minimum cell size for the denominator.

Federal Fiscal Year 2016(10/01/2015 - 9/30/2016)

HospitalProvider Preventable ConditionCasesPer 1000
Discharges
Per 1000
Bed Days
Carson Tahoe Regional Medical CenterStage III And IV Pressure Ulcers10.0760.018
Carson Tahoe Regional Medical CenterFalls And Trauma60.4540.110
Carson Tahoe Regional Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement20.1510.037
Centennial Hills Hospital Medical CenterForeign Object Retained Following Surgery20.1310.034
Centennial Hills Hospital Medical CenterStage III And IV Pressure Ulcers20.1310.034
Centennial Hills Hospital Medical CenterFalls And Trauma80.5250.136
Centennial Hills Hospital Medical CenterCathether-Associated Urinary Tract Infection (UTI)10.0660.017
Centennial Hills Hospital Medical CenterVascular Cathether-Associated Infection30.1970.051
Centennial Hills Hospital Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement20.1310.034
Centennial Hills Hospital Medical CenterSurgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures10.0660.017
Desert Springs Hospital Medical CenterStage III And IV Pressure Ulcers20.1620.029
Desert Springs Hospital Medical CenterFalls And Trauma30.2430.043
Desert Springs Hospital Medical CenterCathether-Associated Urinary Tract Infection (UTI)20.1620.029
Desert Springs Hospital Medical CenterManifestations Of Poor Glycemic Control10.0810.014
MountainView HospitalFalls And Trauma30.1300.027
MountainView HospitalVascular Cathether-Associated Infection10.0430.009
MountainView HospitalManifestations Of Poor Glycemic Control10.0430.009
North Vista HospitalFalls And Trauma50.6210.117
Northeastern Nevada Regional HospitalFalls And Trauma10.4160.151
Northern Nevada Medical CenterFalls And Trauma10.2340.047
Northern Nevada Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement10.2340.047
Renown Regional Medical CenterForeign Object Retained Following Surgery10.0300.006
Renown Regional Medical CenterStage III And IV Pressure Ulcers10.0300.006
Renown Regional Medical CenterFalls And Trauma120.3610.073
Renown Regional Medical CenterCathether-Associated Urinary Tract Infection (UTI)40.1200.024
Renown Regional Medical CenterVascular Cathether-Associated Infection20.0600.012
Renown Regional Medical CenterManifestations Of Poor Glycemic Control30.0900.018
Renown Regional Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement40.1200.024
Renown Regional Medical CenterSurgical Site Infection (SSI) Following Certain Orthopedic Procedures Of Spine, Shoulder Or Elbow10.0300.006
Renown South Meadows Medical CenterManifestations Of Poor Glycemic Control30.9040.297
Saint Mary's Regional Medical CenterFalls And Trauma10.0580.015
Saint Mary's Regional Medical CenterVascular Cathether-Associated Infection10.0580.015
Saint Mary's Regional Medical CenterSurgical Site Infection (SSI) Following Certain Orthopedic Procedures Of Spine, Shoulder Or Elbow10.0580.015
Southern Hills Hospital and Medical CenterFalls And Trauma20.1960.046
Spring Valley Hospital Medical CenterStage III And IV Pressure Ulcers10.0590.012
Spring Valley Hospital Medical CenterFalls And Trauma30.1760.037
Spring Valley Hospital Medical CenterCathether-Associated Urinary Tract Infection (UTI)10.0590.012
Spring Valley Hospital Medical CenterVascular Cathether-Associated Infection10.0590.012
Spring Valley Hospital Medical CenterManifestations Of Poor Glycemic Control20.1170.025
Spring Valley Hospital Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement20.1170.025
St. Rose Dominican Hospitals - Rose de Lima CampusFalls And Trauma20.4110.071
St. Rose Dominican Hospitals - Rose de Lima CampusCathether-Associated Urinary Tract Infection (UTI)20.4110.071
St. Rose Dominican Hospitals - Rose de Lima CampusManifestations Of Poor Glycemic Control10.2060.036
St. Rose Dominican Hospitals - San Martin CampusFalls And Trauma20.2410.055
St. Rose Dominican Hospitals - San Martin CampusCathether-Associated Urinary Tract Infection (UTI)20.2410.055
St. Rose Dominican Hospitals - Siena CampusFalls And Trauma70.3350.077
St. Rose Dominican Hospitals - Siena CampusCathether-Associated Urinary Tract Infection (UTI)80.3830.088
St. Rose Dominican Hospitals - Siena CampusVascular Cathether-Associated Infection30.1440.033
St. Rose Dominican Hospitals - Siena CampusManifestations Of Poor Glycemic Control50.2390.055
St. Rose Dominican Hospitals - Siena CampusDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement90.4310.099
St. Rose Dominican Hospitals - Siena CampusSurgical Site Infection (SSI) Following Certain Orthopedic Procedures Of Spine, Shoulder Or Elbow10.0480.011
Summerlin Hospital Medical CenterForeign Object Retained Following Surgery20.0780.017
Summerlin Hospital Medical CenterFalls And Trauma20.0780.017
Summerlin Hospital Medical CenterCathether-Associated Urinary Tract Infection (UTI)10.0390.008
Summerlin Hospital Medical CenterVascular Cathether-Associated Infection30.1170.025
Summerlin Hospital Medical CenterManifestations Of Poor Glycemic Control20.0780.017
Sunrise Hospital and Medical CenterStage III And IV Pressure Ulcers10.0280.005
Sunrise Hospital and Medical CenterFalls And Trauma20.0560.010
Sunrise Hospital and Medical CenterVascular Cathether-Associated Infection30.0840.014
Sunrise Hospital and Medical CenterDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement10.0280.005
University Medical Center of Southern NevadaFalls And Trauma20.0860.015
University Medical Center of Southern NevadaCathether-Associated Urinary Tract Infection (UTI)30.1290.023
University Medical Center of Southern NevadaVascular Cathether-Associated Infection30.1290.023
University Medical Center of Southern NevadaDeep Vein Thrombosis (DTV) / Pulmonary Embolism (PE) With Total Knee Or Hip Replacement20.0860.015
Valley Hospital Medical CenterForeign Object Retained Following Surgery10.0700.012
Valley Hospital Medical CenterStage III And IV Pressure Ulcers10.0700.012
Valley Hospital Medical CenterFalls And Trauma30.2110.036
Valley Hospital Medical CenterCathether-Associated Urinary Tract Infection (UTI)20.1410.024
Valley Hospital Medical CenterVascular Cathether-Associated Infection10.0700.012

Specifications For Record To Be Flagged As PPC

PPCs are based on the CMS Hospital-Acquired Conditions A Record Is Counted As A PPC If It Meets The Diagnosis Code And Present on Admission (POA) Conditions
  • The First 8 (Diagnosis Order 2-9) Secondary Diagnoses (ICD-10-CM Codes With The Decimal Point Removed) Are Looked At To Flag A PPC
  • Present on Admission (POA) Code Of "N" Or "U" Required To Consider Diagnosis As A PPC
Present on Admission (POA) Codes Definitions:
  • Y = Diagnosis Was POA
  • N = Diagnosis Was not POA
  • U = Documentation Insufficient To Determine If The Condition Was POA
  • W = Provider Unable To Clinically Determine Whether The Condition Was POA
  • 1 = Unreported/Not Used

Federal Fiscal Year 2015(10/01/2014 - 9/30/2015)

HospitalProvider Preventable ConditionCasesPer 1000
Discharges
Per 1000
Bed Days
Carson Tahoe Regional Medical CenterFalls And Trauma10.0790.019
Carson Tahoe Regional Medical CenterManifestations Of Poor Glycemic Control10.0790.019
Carson Tahoe Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0790.019
Carson Tahoe Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0790.019
Centennial Hills Hospital Medical CenterFalls And Trauma40.2770.082
Centennial Hills Hospital Medical CenterVascular Catheter Associated Infection10.0690.020
Centennial Hills Hospital Medical CenterManifestations Of Poor Glycemic Control10.0690.020
Centennial Hills Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures50.3460.102
Centennial Hills Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.1390.041
Desert Springs Hospital Medical CenterPressure Ulcer Stages III And IV20.1660.027
Desert Springs Hospital Medical CenterFalls And Trauma40.3320.055
Desert Springs Hospital Medical CenterVascular Catheter Associated Infection10.0830.014
Desert Springs Hospital Medical CenterManifestations Of Poor Glycemic Control10.0830.014
Desert Springs Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.1660.027
MountainView HospitalPressure Ulcer Stages III And IV20.0880.018
MountainView HospitalFalls And Trauma80.3510.074
MountainView HospitalCatheter Associated Urinary Tract Infection (UTI)20.0880.018
MountainView HospitalVascular Catheter Associated Infection20.0880.018
MountainView HospitalDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0440.009
Northeastern Nevada Regional HospitalFalls And Trauma41.4350.526
Northern Nevada Medical CenterPressure Ulcer Stages III And IV20.5380.101
Northern Nevada Medical CenterManifestations Of Poor Glycemic Control10.2690.051
Northern Nevada Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.2690.051
Renown Regional Medical CenterForeign Object Retained After Surgery10.0320.007
Renown Regional Medical CenterPressure Ulcer Stages III And IV10.0320.007
Renown Regional Medical CenterFalls And Trauma70.2260.046
Renown Regional Medical CenterVascular Catheter Associated Infection30.0970.020
Renown Regional Medical CenterManifestations Of Poor Glycemic Control40.1290.026
Renown Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures20.0650.013
Renown Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures30.0970.020
Renown Regional Medical CenterIatrogenic Pneumothorax with Venous Catheterization30.0970.020
Renown South Meadows Medical CenterFalls And Trauma20.6740.227
Renown South Meadows Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.3370.113
Saint Mary's Regional Medical CenterForeign Object Retained After Surgery10.0570.016
Saint Mary's Regional Medical CenterFalls And Trauma10.0570.016
Saint Mary's Regional Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0570.016
Saint Mary's Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0570.016
Southern Hills Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures70.7130.175
Spring Valley Hospital Medical CenterFalls And Trauma20.1140.025
Spring Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0570.012
Spring Valley Hospital Medical CenterVascular Catheter Associated Infection10.0570.012
Spring Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures70.3990.087
St. Rose Dominican Hospitals - Rose de Lima CampusFalls And Trauma20.3890.065
St. Rose Dominican Hospitals - Rose de Lima CampusCatheter Associated Urinary Tract Infection (UTI)20.3890.065
St. Rose Dominican Hospitals - Rose de Lima CampusManifestations Of Poor Glycemic Control10.1940.033
St. Rose Dominican Hospitals - San Martin CampusCatheter Associated Urinary Tract Infection (UTI)20.2620.056
St. Rose Dominican Hospitals - San Martin CampusVascular Catheter Associated Infection50.6540.140
St. Rose Dominican Hospitals - San Martin CampusManifestations Of Poor Glycemic Control20.2620.056
St. Rose Dominican Hospitals - San Martin CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.1310.028
St. Rose Dominican Hospitals - San Martin CampusIatrogenic Pneumothorax with Venous Catheterization30.3920.084
St. Rose Dominican Hospitals - Siena CampusForeign Object Retained After Surgery10.0560.013
St. Rose Dominican Hospitals - Siena CampusFalls And Trauma70.3910.089
St. Rose Dominican Hospitals - Siena CampusCatheter Associated Urinary Tract Infection (UTI)50.2800.064
St. Rose Dominican Hospitals - Siena CampusVascular Catheter Associated Infection60.3350.077
St. Rose Dominican Hospitals - Siena CampusManifestations Of Poor Glycemic Control20.1120.026
St. Rose Dominican Hospitals - Siena CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures150.8390.191
St. Rose Dominican Hospitals - Siena CampusIatrogenic Pneumothorax with Venous Catheterization40.2240.051
Summerlin Hospital Medical CenterForeign Object Retained After Surgery10.0420.009
Summerlin Hospital Medical CenterFalls And Trauma30.1270.027
Summerlin Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0420.009
Summerlin Hospital Medical CenterVascular Catheter Associated Infection40.1700.036
Summerlin Hospital Medical CenterManifestations Of Poor Glycemic Control10.0420.009
Summerlin Hospital Medical CenterSurgical Site Infection Following Cardiac Implantable Electronic Device (CIED)10.0420.009
Summerlin Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization50.2120.045
Sunrise Hospital and Medical CenterPressure Ulcer Stages III And IV10.0270.005
Sunrise Hospital and Medical CenterFalls And Trauma40.1100.020
Sunrise Hospital and Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0270.005
Sunrise Hospital and Medical CenterVascular Catheter Associated Infection20.0550.010
Sunrise Hospital and Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0270.005
Sunrise Hospital and Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.0270.005
University Medical Center of Southern NevadaFalls And Trauma10.0440.008
University Medical Center of Southern NevadaVascular Catheter Associated Infection10.0440.008
University Medical Center of Southern NevadaManifestations Of Poor Glycemic Control20.0890.016
University Medical Center of Southern NevadaDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0440.008
University Medical Center of Southern NevadaIatrogenic Pneumothorax with Venous Catheterization10.0440.008
Valley Hospital Medical CenterFalls And Trauma20.1460.025
Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)20.1460.025
Valley Hospital Medical CenterVascular Catheter Associated Infection10.0730.013
Valley Hospital Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures30.2200.038
Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0730.013
Valley Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.1460.025

Specifications For Record To Be Flagged As PPC

PPCs are based on the CMS Hospital-Acquired Conditions A Record Is Counted As A PPC If It Meets The Diagnosis Code And POA Conditions
Please See Below For Information About Diagnosis Code & POA Columns
Provider Preventable ConditionDiagnosis CodePOA
Air Embolism9991Yes
Blood Incompatibility99960-99963
99969
Yes
Catheter Associated Urinary Tract Infection (UTI)99664Yes
Deep Vein Thrombosis And Pulmonary Embolism
Following Certain Orthopedic Procedures
41511
41513
41519
45340-45342
Yes
Other Condition: One of the following Procedure Codes: 0085-0087, 8151-8152, 8154
Falls And TraumaCodes within these ranges on the CC/MCC list:
Fracture800-829Yes
Dislocation830-839
Intracranial Injury850-854
Crushing Injury925-929
Burn940-949
Other Injuries991-994
Foreign Object Retained After Surgery9984
9987
Yes
Iatrogenic Pneumothorax With Venous Catheterization5121Yes
Other Condition: Procedure Code: 3893
Manifestations Of Poor Glycemic ControlCodes within these ranges on the CC/MCC list:
Secondary Diabetes with Ketoacidosis24910-24911Yes
Secondary Diabetes with Hyperosmolarity24920-24921
Diabetic Ketoacidosis25010-25013
Nonketotic Hyperosmolar Coma25020-25023
Hypoglycemic Coma2510
Pressure Ulcer Stages III And IV70723-70724Yes
Surgical Site Infection
Following Bariatric Surgery For Obesity
53901
53981
99859
Yes
Other Condition: Principal Diagnosis: 27801
Other Condition: One of the following Procedure Codes: 4438-4439, 4495
Surgical Site Infection
Following Cardiac Implantable Electronic Device (CIED)
99661
99859
Yes
Other Condition: One of the following Procedure Codes:
0050-0054, 3774-3777, 3779, 3780-3783, 3785-3787, 3789, 3794, 3796, 3798
Surgical Site Infection
Following Certain Orthopedic Procedures
99667
99859
Yes
Other Condition: One of the following Procedure Codes:
8101-8108, 8123-8124, 8131-8138, 8183, 8185
Surgical Site Infection, Mediastinitis,
Following Coronary Artery Bypass Graft (CABG)
5192Yes
Other Condition: One of the following Procedure Codes: 3610-3619
Vascular Catheter Associated Infection99931-99933Yes
Diagnosis Code: ICD-9-CM Codes With The Decimal Point Removed
  • The First 8 Secondary Diagnoses (Diagnosis Order 2-9) Are Looked At To Flag A PPC
  • All Diagnosis Codes Used Are In The CC/MCC List
  • Diagnosis Codes With An Excluding Principal Diagnosis Code Are Not Used
  • CC/MCC & CC/MCC Exclusions Lists Can Be Found At CMS Website
POA: Present On Admission Indicator Required:
  • Yes = POA Code Of "N" Or "U" Required To Consider Diagnosis As A PPC
  • No = POA Code Ignored (Can Be Any Value Or Missing)
POA Codes Definitions:
  • Y = Diagnosis Was POA
  • N = Diagnosis Was not POA
  • U = Documentation Insufficient To Determine If The Condition Was POA
  • W = Provider Unable To Clinically Determine Whether The Condition Was POA
  • 1 = Unreported/Not Used

Federal Fiscal Year 2014(10/01/2013 - 9/30/2014)

HospitalProvider Preventable ConditionCasesPer 1000
Discharges
Per 1000
Bed Days
Banner Churchill Community HospitalFalls And Trauma10.4630.153
Carson Tahoe Regional Medical CenterForeign Object Retained After Surgery10.0870.020
Carson Tahoe Regional Medical CenterFalls And Trauma10.0870.020
Carson Tahoe Regional Medical CenterVascular Catheter Associated Infection20.1740.040
Carson Tahoe Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.1740.040
Centennial Hills Hospital Medical CenterPressure Ulcer Stages III And IV10.0800.024
Centennial Hills Hospital Medical CenterFalls And Trauma30.2390.073
Centennial Hills Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)20.1590.049
Centennial Hills Hospital Medical CenterManifestations Of Poor Glycemic Control30.2390.073
Centennial Hills Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures60.4780.146
Desert Springs Hospital Medical CenterFalls And Trauma80.7080.109
Desert Springs Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0890.014
Desert Springs Hospital Medical CenterVascular Catheter Associated Infection10.0890.014
Desert Springs Hospital Medical CenterManifestations Of Poor Glycemic Control20.1770.027
Desert Springs Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization60.5310.081
MountainView HospitalPressure Ulcer Stages III And IV20.0990.020
MountainView HospitalFalls And Trauma40.1980.040
MountainView HospitalCatheter Associated Urinary Tract Infection (UTI)20.0990.020
MountainView HospitalVascular Catheter Associated Infection20.0990.020
MountainView HospitalManifestations Of Poor Glycemic Control10.0500.010
MountainView HospitalDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0500.010
MountainView HospitalIatrogenic Pneumothorax with Venous Catheterization20.0990.020
North Vista HospitalPressure Ulcer Stages III And IV20.3570.048
North Vista HospitalVascular Catheter Associated Infection20.3570.048
North Vista HospitalManifestations Of Poor Glycemic Control20.3570.048
Northern Nevada Medical CenterFalls And Trauma10.2850.052
Northern Nevada Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.5700.105
Renown Regional Medical CenterForeign Object Retained After Surgery10.0320.007
Renown Regional Medical CenterPressure Ulcer Stages III And IV50.1600.034
Renown Regional Medical CenterFalls And Trauma50.1600.034
Renown Regional Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0320.007
Renown Regional Medical CenterVascular Catheter Associated Infection60.1920.041
Renown Regional Medical CenterManifestations Of Poor Glycemic Control80.2560.055
Renown Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures20.0640.014
Renown Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.0640.014
Renown Regional Medical CenterIatrogenic Pneumothorax with Venous Catheterization40.1280.027
Renown South Meadows Medical CenterSurgical Site Infection Following Bariatric Surgery For Obesity10.3440.116
Renown South Meadows Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.3440.116
Saint Mary's Regional Medical CenterForeign Object Retained After Surgery10.0590.016
Saint Mary's Regional Medical CenterFalls And Trauma30.1770.047
Saint Mary's Regional Medical CenterVascular Catheter Associated Infection10.0590.016
Saint Mary's Regional Medical CenterManifestations Of Poor Glycemic Control10.0590.016
Southern Hills Hospital and Medical CenterFalls And Trauma20.2290.057
Southern Hills Hospital and Medical CenterManifestations Of Poor Glycemic Control10.1150.028
Southern Hills Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.2290.057
Southern Hills Hospital and Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.1150.028
Spring Valley Hospital Medical CenterPressure Ulcer Stages III And IV10.0570.012
Spring Valley Hospital Medical CenterFalls And Trauma30.1710.037
Spring Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures100.5690.123
Spring Valley Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.0570.012
St. Rose Dominican Hospitals - Rose de Lima CampusPressure Ulcer Stages III And IV10.1850.033
St. Rose Dominican Hospitals - Rose de Lima CampusFalls And Trauma20.3700.066
St. Rose Dominican Hospitals - Rose de Lima CampusIatrogenic Pneumothorax with Venous Catheterization10.1850.033
St. Rose Dominican Hospitals - San Martin CampusFalls And Trauma30.4150.093
St. Rose Dominican Hospitals - San Martin CampusVascular Catheter Associated Infection30.4150.093
St. Rose Dominican Hospitals - San Martin CampusManifestations Of Poor Glycemic Control20.2770.062
St. Rose Dominican Hospitals - San Martin CampusSurgical Site Infection Following Cardiac Implantable Electronic Device (CIED)10.1380.031
St. Rose Dominican Hospitals - San Martin CampusIatrogenic Pneumothorax with Venous Catheterization20.2770.062
St. Rose Dominican Hospitals - Siena CampusFalls And Trauma70.3910.085
St. Rose Dominican Hospitals - Siena CampusCatheter Associated Urinary Tract Infection (UTI)60.3350.072
St. Rose Dominican Hospitals - Siena CampusVascular Catheter Associated Infection30.1670.036
St. Rose Dominican Hospitals - Siena CampusSurgical Site Infection Following Certain Orthopedic Procedures10.0560.012
St. Rose Dominican Hospitals - Siena CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures170.9490.205
St. Rose Dominican Hospitals - Siena CampusIatrogenic Pneumothorax with Venous Catheterization80.4460.097
Summerlin Hospital Medical CenterFalls And Trauma60.2850.059
Summerlin Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)60.2850.059
Summerlin Hospital Medical CenterVascular Catheter Associated Infection10.0470.010
Summerlin Hospital Medical CenterManifestations Of Poor Glycemic Control10.0470.010
Summerlin Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures30.1420.029
Summerlin Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization30.1420.029
Sunrise Hospital and Medical CenterForeign Object Retained After Surgery20.0610.011
Sunrise Hospital and Medical CenterPressure Ulcer Stages III And IV20.0610.011
Sunrise Hospital and Medical CenterFalls And Trauma40.1220.022
Sunrise Hospital and Medical CenterCatheter Associated Urinary Tract Infection (UTI)30.0910.017
Sunrise Hospital and Medical CenterVascular Catheter Associated Infection40.1220.022
Sunrise Hospital and Medical CenterSurgical Site Infection Following Cardiac Implantable Electronic Device (CIED)10.0300.006
Sunrise Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0300.006
Sunrise Hospital and Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.0610.011
University Medical Center of Southern NevadaFalls And Trauma20.0790.016
University Medical Center of Southern NevadaManifestations Of Poor Glycemic Control20.0790.016
University Medical Center of Southern NevadaDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0400.008
Valley Hospital Medical CenterPressure Ulcer Stages III And IV10.0720.013
Valley Hospital Medical CenterFalls And Trauma20.1440.026
Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)40.2890.052
Valley Hospital Medical CenterVascular Catheter Associated Infection10.0720.013
Valley Hospital Medical CenterManifestations Of Poor Glycemic Control10.0720.013
Valley Hospital Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0720.013
Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures30.2170.039
Valley Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization30.2170.039

Specifications For Record To Be Flagged As PPC

PPCs are based on the CMS Hospital-Acquired Conditions A Record Is Counted As A PPC If It Meets The Diagnosis Code And POA Conditions
Please See Below For Information About Diagnosis Code & POA Columns
Provider Preventable ConditionDiagnosis CodePOA
Air Embolism9991Yes
Blood Incompatibility99960-99963
99969
Yes
Catheter Associated Urinary Tract Infection (UTI)99664Yes
Deep Vein Thrombosis And Pulmonary Embolism
Following Certain Orthopedic Procedures
41511
41513
41519
45340-45342
Yes
Other Condition: One of the following Procedure Codes: 0085-0087, 8151-8152, 8154
Falls And TraumaCodes within these ranges on the CC/MCC list:
Fracture800-829Yes
Dislocation830-839
Intracranial Injury850-854
Crushing Injury925-929
Burn940-949
Other Injuries991-994
Foreign Object Retained After Surgery9984
9987
Yes
Iatrogenic Pneumothorax With Venous Catheterization5121Yes
Other Condition: Procedure Code: 3893
Manifestations Of Poor Glycemic ControlCodes within these ranges on the CC/MCC list:
Secondary Diabetes with Ketoacidosis24910-24911Yes
Secondary Diabetes with Hyperosmolarity24920-24921
Diabetic Ketoacidosis25010-25013
Nonketotic Hyperosmolar Coma25020-25023
Hypoglycemic Coma2510
Pressure Ulcer Stages III And IV70723-70724Yes
Surgical Site Infection
Following Bariatric Surgery For Obesity
53901
53981
99859
Yes
Other Condition: Principal Diagnosis: 27801
Other Condition: One of the following Procedure Codes: 4438-4439, 4495
Surgical Site Infection
Following Cardiac Implantable Electronic Device (CIED)
99661
99859
Yes
Other Condition: One of the following Procedure Codes:
0050-0054, 3774-3777, 3779, 3780-3783, 3785-3787, 3789, 3794, 3796, 3798
Surgical Site Infection
Following Certain Orthopedic Procedures
99667
99859
Yes
Other Condition: One of the following Procedure Codes:
8101-8108, 8123-8124, 8131-8138, 8183, 8185
Surgical Site Infection, Mediastinitis,
Following Coronary Artery Bypass Graft (CABG)
5192Yes
Other Condition: One of the following Procedure Codes: 3610-3619
Vascular Catheter Associated Infection99931-99933Yes
Diagnosis Code: ICD-9-CM Codes With The Decimal Point Removed
  • The First 8 Secondary Diagnoses (Diagnosis Order 2-9) Are Looked At To Flag A PPC
  • All Diagnosis Codes Used Are In The CC/MCC List
  • Diagnosis Codes With An Excluding Principal Diagnosis Code Are Not Used
  • CC/MCC & CC/MCC Exclusions Lists Can Be Found At CMS Website
POA: Present On Admission Indicator Required:
  • Yes = POA Code Of "N" Or "U" Required To Consider Diagnosis As A PPC
  • No = POA Code Ignored (Can Be Any Value Or Missing)
POA Codes Definitions:
  • Y = Diagnosis Was POA
  • N = Diagnosis Was not POA
  • U = Documentation Insufficient To Determine If The Condition Was POA
  • W = Provider Unable To Clinically Determine Whether The Condition Was POA
  • 1 = Unreported/Not Used

Federal Fiscal Year 2013(10/01/2012 - 9/30/2013)

HospitalProvider Preventable ConditionCasesPer 1000
Discharges
Per 1000
Bed Days
Banner Churchill Community HospitalFalls And Trauma10.4470.150
Carson Tahoe Regional Medical CenterFalls And Trauma30.2750.066
Carson Tahoe Regional Medical CenterCatheter Associated Urinary Tract Infection (UTI)20.1830.044
Carson Tahoe Regional Medical CenterVascular Catheter Associated Infection20.1830.044
Carson Tahoe Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0920.022
Centennial Hills Hospital Medical CenterFalls And Trauma50.4300.134
Centennial Hills Hospital Medical CenterVascular Catheter Associated Infection60.5160.161
Centennial Hills Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.1720.054
Desert Springs Hospital Medical CenterPressure Ulcer Stages III And IV10.0910.014
Desert Springs Hospital Medical CenterFalls And Trauma80.7250.114
Desert Springs Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)20.1810.028
Desert Springs Hospital Medical CenterVascular Catheter Associated Infection30.2720.043
Desert Springs Hospital Medical CenterManifestations Of Poor Glycemic Control20.1810.028
Desert Springs Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization40.3630.057
MountainView HospitalFalls And Trauma30.1630.035
MountainView HospitalCatheter Associated Urinary Tract Infection (UTI)20.1090.023
MountainView HospitalVascular Catheter Associated Infection40.2170.046
MountainView HospitalDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.1090.023
North Vista HospitalPressure Ulcer Stages III And IV40.7010.087
North Vista HospitalFalls And Trauma40.7010.087
North Vista HospitalSurgical Site Infection Following Certain Orthopedic Procedures10.1750.022
North Vista HospitalIatrogenic Pneumothorax with Venous Catheterization10.1750.022
Northeastern Nevada Regional HospitalFalls And Trauma10.2960.110
Northern Nevada Medical CenterFalls And Trauma61.6140.320
Northern Nevada Medical CenterVascular Catheter Associated Infection10.2690.053
Northern Nevada Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures20.5380.107
Northern Nevada Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.2690.053
Northern Nevada Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.2690.053
Renown Regional Medical CenterForeign Object Retained After Surgery10.0320.007
Renown Regional Medical CenterPressure Ulcer Stages III And IV50.1590.034
Renown Regional Medical CenterFalls And Trauma60.1910.041
Renown Regional Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0320.007
Renown Regional Medical CenterVascular Catheter Associated Infection20.0640.014
Renown Regional Medical CenterManifestations Of Poor Glycemic Control40.1270.027
Renown Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0320.007
Renown Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.0640.014
Renown Regional Medical CenterIatrogenic Pneumothorax with Venous Catheterization50.1590.034
Saint Mary's Regional Medical CenterForeign Object Retained After Surgery10.0600.017
Saint Mary's Regional Medical CenterPressure Ulcer Stages III And IV10.0600.017
Saint Mary's Regional Medical CenterFalls And Trauma40.2410.067
Saint Mary's Regional Medical CenterVascular Catheter Associated Infection30.1810.050
Saint Mary's Regional Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.0600.017
Southern Hills Hospital and Medical CenterFalls And Trauma20.2460.062
Southern Hills Hospital and Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.1230.031
Southern Hills Hospital and Medical CenterVascular Catheter Associated Infection30.3690.094
Southern Hills Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.1230.031
Southern Hills Hospital and Medical CenterIatrogenic Pneumothorax with Venous Catheterization10.1230.031
Spring Valley Hospital Medical CenterFalls And Trauma70.4230.094
Spring Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0600.013
Spring Valley Hospital Medical CenterVascular Catheter Associated Infection10.0600.013
Spring Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures50.3020.067
St. Rose Dominican Hospitals - Rose de Lima CampusFalls And Trauma10.1640.032
St. Rose Dominican Hospitals - Rose de Lima CampusCatheter Associated Urinary Tract Infection (UTI)20.3270.063
St. Rose Dominican Hospitals - Rose de Lima CampusVascular Catheter Associated Infection10.1640.032
St. Rose Dominican Hospitals - Rose de Lima CampusManifestations Of Poor Glycemic Control20.3270.063
St. Rose Dominican Hospitals - Rose de Lima CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.1640.032
St. Rose Dominican Hospitals - San Martin CampusFalls And Trauma10.1260.030
St. Rose Dominican Hospitals - San Martin CampusCatheter Associated Urinary Tract Infection (UTI)10.1260.030
St. Rose Dominican Hospitals - San Martin CampusVascular Catheter Associated Infection10.1260.030
St. Rose Dominican Hospitals - San Martin CampusIatrogenic Pneumothorax with Venous Catheterization40.5030.122
St. Rose Dominican Hospitals - Siena CampusFalls And Trauma70.3620.092
St. Rose Dominican Hospitals - Siena CampusCatheter Associated Urinary Tract Infection (UTI)10.0520.013
St. Rose Dominican Hospitals - Siena CampusVascular Catheter Associated Infection50.2590.066
St. Rose Dominican Hospitals - Siena CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures160.8280.211
St. Rose Dominican Hospitals - Siena CampusIatrogenic Pneumothorax with Venous Catheterization30.1550.040
Summerlin Hospital Medical CenterPressure Ulcer Stages III And IV10.0480.010
Summerlin Hospital Medical CenterFalls And Trauma30.1450.031
Summerlin Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0480.010
Summerlin Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.0960.021
Sunrise Hospital and Medical CenterForeign Object Retained After Surgery20.0630.013
Sunrise Hospital and Medical CenterFalls And Trauma60.1900.038
Sunrise Hospital and Medical CenterCatheter Associated Urinary Tract Infection (UTI)40.1270.025
Sunrise Hospital and Medical CenterVascular Catheter Associated Infection60.1900.038
Sunrise Hospital and Medical CenterManifestations Of Poor Glycemic Control10.0320.006
Sunrise Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.0630.013
Sunrise Hospital and Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.0630.013
University Medical Center of Southern NevadaForeign Object Retained After Surgery10.0370.007
University Medical Center of Southern NevadaPressure Ulcer Stages III And IV20.0730.015
University Medical Center of Southern NevadaFalls And Trauma60.2190.045
University Medical Center of Southern NevadaCatheter Associated Urinary Tract Infection (UTI)10.0370.007
University Medical Center of Southern NevadaVascular Catheter Associated Infection70.2560.052
University Medical Center of Southern NevadaManifestations Of Poor Glycemic Control20.0730.015
University Medical Center of Southern NevadaSurgical Site Infection Following Bariatric Surgery For Obesity10.0370.007
University Medical Center of Southern NevadaIatrogenic Pneumothorax with Venous Catheterization20.0730.015
Valley Hospital Medical CenterFalls And Trauma20.1240.025
Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0620.012
Valley Hospital Medical CenterVascular Catheter Associated Infection20.1240.025
Valley Hospital Medical CenterManifestations Of Poor Glycemic Control10.0620.012
Valley Hospital Medical CenterIatrogenic Pneumothorax with Venous Catheterization20.1240.025

Specifications For Record To Be Flagged As PPC

PPCs are based on the CMS Hospital-Acquired Conditions A Record Is Counted As A PPC If It Meets The Diagnosis Code And POA Conditions
Please See Below For Information About Diagnosis Code & POA Columns
Provider Preventable ConditionDiagnosis CodePOA
Air Embolism9991Yes
Blood Incompatibility99960-99963
99969
Yes
Catheter Associated Urinary Tract Infection (UTI)99664Yes
Deep Vein Thrombosis And Pulmonary Embolism
Following Certain Orthopedic Procedures
41511
41513
41519
45340-45342
Yes
Other Condition: One of the following Procedure Codes: 0085-0087, 8151-8152, 8154
Falls And TraumaCodes within these ranges on the CC/MCC list:
Fracture800-829Yes
Dislocation830-839
Intracranial Injury850-854
Crushing Injury925-929
Burn940-949
Other Injuries991-994
Foreign Object Retained After Surgery9984
9987
Yes
Iatrogenic Pneumothorax With Venous Catheterization5121Yes
Other Condition: Procedure Code: 3893
Manifestations Of Poor Glycemic ControlCodes within these ranges on the CC/MCC list:
Secondary Diabetes with Ketoacidosis24910-24911Yes
Secondary Diabetes with Hyperosmolarity24920-24921
Diabetic Ketoacidosis25010-25013
Nonketotic Hyperosmolar Coma25020-25023
Hypoglycemic Coma2510
Pressure Ulcer Stages III And IV70723-70724Yes
Surgical Site Infection
Following Bariatric Surgery For Obesity
53901
53981
99859
Yes
Other Condition: Principal Diagnosis: 27801
Other Condition: One of the following Procedure Codes: 4438-4439, 4495
Surgical Site Infection
Following Cardiac Implantable Electronic Device (CIED)
99661
99859
Yes
Other Condition: One of the following Procedure Codes:
0050-0054, 3774-3777, 3779, 3780-3783, 3785-3787, 3789, 3794, 3796, 3798
Surgical Site Infection
Following Certain Orthopedic Procedures
99667
99859
Yes
Other Condition: One of the following Procedure Codes:
8101-8108, 8123-8124, 8131-8138, 8183, 8185
Surgical Site Infection, Mediastinitis,
Following Coronary Artery Bypass Graft (CABG)
5192Yes
Other Condition: One of the following Procedure Codes: 3610-3619
Vascular Catheter Associated Infection99931-99933Yes
Diagnosis Code: ICD-9-CM Codes With The Decimal Point Removed
  • The First 8 Secondary Diagnoses (Diagnosis Order 2-9) Are Looked At To Flag A PPC
  • All Diagnosis Codes Used Are In The CC/MCC List
  • Diagnosis Codes With An Excluding Principal Diagnosis Code Are Not Used
  • CC/MCC & CC/MCC Exclusions Lists Can Be Found At CMS Website
POA: Present On Admission Indicator Required:
  • Yes = POA Code Of "N" Or "U" Required To Consider Diagnosis As A PPC
  • No = POA Code Ignored (Can Be Any Value Or Missing)
POA Codes Definitions:
  • Y = Diagnosis Was POA
  • N = Diagnosis Was not POA
  • U = Documentation Insufficient To Determine If The Condition Was POA
  • W = Provider Unable To Clinically Determine Whether The Condition Was POA
  • 1 = Unreported/Not Used

Federal Fiscal Year 2012(10/01/2011 - 9/30/2012)

HospitalProvider Preventable ConditionCasesPer 1000
Discharges
Per 1000
Bed Days
Banner Churchill Community HospitalFalls And Trauma10.3850.119
Carson Tahoe Regional Medical CenterFalls And Trauma10.0910.022
Carson Tahoe Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0910.022
Centennial Hills Hospital Medical CenterFalls And Trauma60.6040.163
Centennial Hills Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.1010.027
Desert Springs Hospital Medical CenterPressure Ulcer Stages III And IV30.3030.055
Desert Springs Hospital Medical CenterFalls And Trauma20.2020.036
Desert Springs Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.1010.018
Desert Springs Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.2020.036
MountainView HospitalFalls And Trauma70.3850.088
MountainView HospitalCatheter Associated Urinary Tract Infection (UTI)20.1100.025
MountainView HospitalDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0550.013
North Vista HospitalFalls And Trauma30.5630.067
North Vista HospitalVascular Catheter Associated Infection10.1880.022
Northern Nevada Medical CenterPressure Ulcer Stages III And IV10.2620.053
Northern Nevada Medical CenterFalls And Trauma61.5690.316
Northern Nevada Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.2620.053
Renown Regional Medical CenterPressure Ulcer Stages III And IV30.0940.020
Renown Regional Medical CenterFalls And Trauma80.2510.052
Renown Regional Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0310.007
Renown Regional Medical CenterVascular Catheter Associated Infection10.0310.007
Renown Regional Medical CenterManifestations Of Poor Glycemic Control30.0940.020
Renown Regional Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures20.0630.013
Renown Regional Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures40.1260.026
Renown South Meadows Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.6680.214
Saint Mary's Regional Medical CenterPressure Ulcer Stages III And IV10.0710.018
Saint Mary's Regional Medical CenterFalls And Trauma20.1420.036
Saint Mary's Regional Medical CenterVascular Catheter Associated Infection20.1420.036
Southern Hills Hospital and Medical CenterFalls And Trauma30.3800.104
Southern Hills Hospital and Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.2530.069
Spring Valley Hospital Medical CenterForeign Object Retained After Surgery10.0630.014
Spring Valley Hospital Medical CenterFalls And Trauma30.1900.043
Spring Valley Hospital Medical CenterVascular Catheter Associated Infection10.0630.014
Spring Valley Hospital Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0630.014
Spring Valley Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures140.8890.202
St. Rose Dominican Hospitals - Rose de Lima CampusFalls And Trauma20.3120.055
St. Rose Dominican Hospitals - Rose de Lima CampusCatheter Associated Urinary Tract Infection (UTI)10.1560.028
St. Rose Dominican Hospitals - Rose de Lima CampusManifestations Of Poor Glycemic Control10.1560.028
St. Rose Dominican Hospitals - Rose de Lima CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures20.3120.055
St. Rose Dominican Hospitals - San Martin CampusPressure Ulcer Stages III And IV10.1140.026
St. Rose Dominican Hospitals - San Martin CampusFalls And Trauma10.1140.026
St. Rose Dominican Hospitals - San Martin CampusCatheter Associated Urinary Tract Infection (UTI)10.1140.026
St. Rose Dominican Hospitals - San Martin CampusVascular Catheter Associated Infection20.2280.051
St. Rose Dominican Hospitals - Siena CampusFalls And Trauma60.3080.077
St. Rose Dominican Hospitals - Siena CampusVascular Catheter Associated Infection40.2060.051
St. Rose Dominican Hospitals - Siena CampusDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures80.4110.102
Summerlin Hospital Medical CenterFalls And Trauma80.3850.079
Summerlin Hospital Medical CenterVascular Catheter Associated Infection10.0480.010
Summerlin Hospital Medical CenterManifestations Of Poor Glycemic Control10.0480.010
Summerlin Hospital Medical CenterDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0480.010
Sunrise Hospital and Medical CenterForeign Object Retained After Surgery20.0620.013
Sunrise Hospital and Medical CenterPressure Ulcer Stages III And IV20.0620.013
Sunrise Hospital and Medical CenterFalls And Trauma20.0620.013
Sunrise Hospital and Medical CenterCatheter Associated Urinary Tract Infection (UTI)10.0310.006
Sunrise Hospital and Medical CenterVascular Catheter Associated Infection20.0620.013
Sunrise Hospital and Medical CenterSurgical Site Infection Following Certain Orthopedic Procedures10.0310.006
University Medical Center of Southern NevadaForeign Object Retained After Surgery20.0730.015
University Medical Center of Southern NevadaPressure Ulcer Stages III And IV60.2190.044
University Medical Center of Southern NevadaFalls And Trauma40.1460.030
University Medical Center of Southern NevadaCatheter Associated Urinary Tract Infection (UTI)60.2190.044
University Medical Center of Southern NevadaVascular Catheter Associated Infection50.1830.037
University Medical Center of Southern NevadaManifestations Of Poor Glycemic Control30.1100.022
University Medical Center of Southern NevadaSurgical Site Infection Following Certain Orthopedic Procedures30.1100.022
University Medical Center of Southern NevadaDeep Vein Thrombosis And Pulmonary Embolism Following Certain Orthopedic Procedures10.0370.007
Valley Hospital Medical CenterForeign Object Retained After Surgery20.1160.024
Valley Hospital Medical CenterFalls And Trauma30.1740.036
Valley Hospital Medical CenterCatheter Associated Urinary Tract Infection (UTI)60.3470.072
Valley Hospital Medical CenterVascular Catheter Associated Infection10.0580.012

Specifications For Record To Be Flagged As PPC

PPCs are based on the CMS Hospital-Acquired Conditions A Record Is Counted As A PPC If It Meets The Diagnosis Code And POA Conditions
Please See Below For Information About Diagnosis Code & POA Columns
Provider Preventable ConditionDiagnosis CodePOA
Air Embolism9991Yes
Blood Incompatibility99960-99963
99969
Yes
Catheter Associated Urinary Tract Infection (UTI)99664Yes
Deep Vein Thrombosis And Pulmonary Embolism
Following Certain Orthopedic Procedures
41511
41513
41519
45340-45342
Yes
Other Condition: One of the following Procedure Codes: 0085-0087, 8151-8152, 8154
Falls And TraumaCodes within these ranges on the CC/MCC list:
Fracture800-829Yes
Dislocation830-839
Intracranial Injury850-854
Crushing Injury925-929
Burn940-949
Other Injuries991-994
Foreign Object Retained After Surgery9984
9987
Yes
Manifestations Of Poor Glycemic ControlCodes within these ranges on the CC/MCC list:
Secondary Diabetes with Ketoacidosis24910-24911Yes
Secondary Diabetes with Hyperosmolarity24920-24921
Diabetic Ketoacidosis25010-25013
Nonketotic Hyperosmolar Coma25020-25023
Hypoglycemic Coma2510
Pressure Ulcer Stages III And IV70723-70724Yes
Surgical Site Infection
Following Bariatric Surgery For Obesity
53901
53981
99859
Yes
Other Condition: Principal Diagnosis: 27801
Other Condition: One of the following Procedure Codes: 4438-4439, 4495
Surgical Site Infection
Following Certain Orthopedic Procedures
99667
99859
Yes
Other Condition: One of the following Procedure Codes:
8101-8108, 8123-8124, 8131-8138, 8183, 8185
Surgical Site Infection, Mediastinitis,
Following Coronary Artery Bypass Graft (CABG)
5192Yes
Other Condition: One of the following Procedure Codes: 3610-3619
Vascular Catheter Associated Infection99931Yes
Diagnosis Code: ICD-9-CM Codes With The Decimal Point Removed
  • The First 8 Secondary Diagnoses (Diagnosis Order 2-9) Are Looked At To Flag A PPC
  • All Diagnosis Codes Used Are In The CC/MCC List
  • Diagnosis Codes With An Excluding Principal Diagnosis Code Are Not Used
  • CC/MCC & CC/MCC Exclusions Lists Can Be Found At CMS Website
POA: Present On Admission Indicator Required:
  • Yes = POA Code Of "N" Or "U" Required To Consider Diagnosis As A PPC
  • No = POA Code Ignored (Can Be Any Value Or Missing)
POA Codes Definitions:
  • Y = Diagnosis Was POA
  • N = Diagnosis Was not POA
  • U = Documentation Insufficient To Determine If The Condition Was POA
  • W = Provider Unable To Clinically Determine Whether The Condition Was POA
  • 1 = Unreported/Not Used