NCDs Add to Never Event List

The Centers for Medicare & Medicaid Services (CMS) posted, Dec. 2, proposed decision memos for three national coverage determinations (NCDs) — adding to the list of “Never Events” Medicare will no longer reimburse as of March 2, 2009. Unlike Hospital Acquired Conditions (HACs), which only pertain to hospitals, these NCD-described events could also affect payment to physicians and other health care providers and suppliers involved in the following types of erroneous surgeries:

The National Quality Forum (NQF) defines Never Events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.

Be on the look out for these types of errors. Documentation must clearly support the procedures you are reporting.

“In general, we determine something to be reasonable and necessary if we find evidence that demonstrates that an item or service improves health outcomes,” CMS said.

When filing a claim, first determine whether the procedure is considered surgery. CMS defines surgery as an invasive procedure in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice. Surgery, then, can be as complex as a multi-organ transplant to as simple as a biopsy, excision, or catheterization. Excluded are instruments such as otoscopes used in examinations and minor procedures such as drawing blood.

Upon determining whether a procedure qualifies as surgery, check the documentation to verify it was the correct procedure performed on the right patient and on the right body part. As written in the NCD for surgery on the wrong body part, a surgical procedure is erroneous if it is performed on the right body part but the wrong location, such as the left side instead of the right side, or the wrong level on a patient’s spine.

Note that unforeseen emergent situations during surgery and requiring immediate attention without first obtaining informed consent are excluded.

In July 2003, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) approved the “Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.” The principal components are:

  • A pre-procedure verification process
  • Marking of the procedure site
  • A “time out” immediately before the start of the procedure
  • Adaptation of the steps to non-operating room settings for procedures performed in other places, such as at bedside.

2009 Universal Protocol updates are available on the Joint Commission’s Web site.


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