Never Events—CMS issues surgical error NCDs and related guidance
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls. The updated list currently contains 28 adverse events, including the following surgical errors:
- Wrong surgical or other invasive procedure performed on a patient;
- Surgical or other invasive procedure performed on the wrong body part; and
- Surgical or other invasive procedure performed on the wrong patient.
Click here to comment on this post.
Such errors could result in serious injury and/or death to Medicare beneficiaries, as well as significant additional costs to correct adverse outcomes arising from these medical mistakes.
On Friday, June 12, 2009, CMS published two related transmittals:
- R101NCD, which sets out national coverage determinations (NCDs) for these three adverse events; and
- R1755CP, which contains related updates to the Medicare Claims Processing Manual.
Under the new NCDs, effective for services performed on and after January 15, 2009, CMS will not cover surgical or other invasive procedures performed in error (e.g., wrong surgery/other invasive procedure, wrong body part, wrong patient), as described above. In addition, Medicare will also not cover hospitalizations and other procedures “related” to these non-covered services.
For purposes of these NCDs, “related” services include, but are not limited to (1) all services provided in the operating room when an error occurs, even though the services would otherwise be individually billable by those providers present; and (2) all related services provided during the same hospitalization in which the error occurred. Related services, however, do not include performance of the correct procedure, nor do they include reasonable and necessary services performed following discharge from the hospital, even if related to the surgical error.
Hospitals and other providers and practitioners are encouraged to read both of these transmittals carefully. Key definitions, specific billing and coding instructions, and details regarding the applicability of prior beneficiary notice in the form of ABNs and HINNs are included.
About the Author: Judith Kares is an instructor for HCPro's Medicare Boot Camp - Hospital Version. Judith has also been involved in the following:
Phil Hinder | Jun 30, 2009 | Reply
Judith
Could you provide a citation to the federal law that authorized CMS to refuse reimbursement of never events and the implementing regulations?
Thanks
Judith Kares | Jul 2, 2009 | Reply
Hi Phil
I don’t have a specific statutory or regulatory cite, but the transmittals cited in the Note (R1755CP and R101NCD) provide background information regarding the identification of the three specific surgical events that have been determined to be “serious, largely preventable, and of concern to both the public and health care providers,” as well as the specific coverage rules that apply to these three events (R1755CP).
Presumably, CMS’ authority for identifying these three events as non-covered arises under their general authority to determine what services are covered under Medicare. The primary coverage requirement established under Medicare law is that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (See §1862(a)(1)(A) of the Social Security Act). It would be difficult to make the argument that the never events meet this threshold coverage requirement.
Judith