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Medical Coding News Archives

CMS Issues NCD for Wrong Surgery

 
June 23, 2009:

The Centers for Medicare and Medicaid Services (CMS) has released a new national coverage determination (NCD) indicating that effective January 15, 2009, CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the physician:

  • Should have performed a different procedure altogether
  • Performed the correct procedure but on the wrong body part
  • Performed the correct procedure but on the wrong patient

The agency indicates that Medicare will also not cover hospitalizations and other services related to these noncovered procedures, including:

  • All services provided in the operating room
  • All providers in the operating room when the error occurs, who could bill individually for their services
  • All related services provided during the same hospitalization

However, it should be noted that any reasonable and necessary services following hospital discharge are covered regardless of whether they are related to the surgical error or not. Emergent situations that occur in the course of surgery and/or whose urgent situation precludes obtaining informed consent are not considered erroneous under this decision. This NCD does not intend to capture changes in the treatment plan upon surgical entry into the patient as a result of discovering pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or when an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae) is discovered. 

CMS defines surgical and other invasive procedures as procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice. A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that patient. Likewise, a surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient, including surgery on the right body part but on the wrong location on the body; for example, left versus right or at the wrong level of the spine. A surgical or other invasive procedure is considered to have been performed on the wrong patient if that procedure is not consistent with the correctly documented informed consent for that patient.

Three new HCPCS level two modifiers have been created to report surgical errors and are to be implemented July 6, 2009, for Medicare Part B Medicare administrative contractors (MAC) and carriers, and on October 5, 2009, for Medicare Part A MACs, fiscal intermediaries (FI), and Fiscal Intermediary Shared System (FISS). 

When a surgical service is performed on the wrong patient, modifier PB should be appended to the code for the procedure performed:

PB Surgery wrong patient

For the correct surgical procedure performed, but on the wrong body part, append modifier PA to the procedure code:

PA Surgery wrong body part

When the wrong procedure is performed on the right patient, modifier PC is appended:

PC Wrong surgery on patient

The claim will be denied and the following comments will appear on the remittance advice statements:

Medicare Summary Notice:
23.17 – Medicare won’t cover these services because they are not considered medically necessary.”

Claim Adjustment Reason Code:
50 – These are non-covered services because this is not deemed a ‘medical necessity” by the payer.

Group Code:
CO – Contractual Obligation

Deborah C. Hall
Clinical/Technical Editor

 

 
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