New Policy, Modifiers for Never Events
The Centers for Medicare & Medicaid Services (CMS) recently updated its Medicare benefit and claims processing policies to reflect National Coverage Determinations (NCD) for noncoverage of certain surgical never events.
Effective Jan. 15, CMS will not cover a surgical or other invasive procedure to treat a medical condition when the practitioner erroneously performs: 1) a wrong surgery on a patient (CAG-00401N); 2) the correct procedure but on the wrong body part (CAG-00402N); or 3) the correct procedure but on the wrong patient (CAG-00403N).
Noncoverage encompasses all related services provided in the operating room when the error occurs, including those separately performed by other physicians, and all other services performed during the same hospital visit.
Following hospital discharge, however, any reasonable and necessary services are covered regardless of whether they are or are not related to the surgical error.
CMS has created three new HCPCS Level II modifiers for practioners, ambulatory surgical centers (ASCs), and hospital outpatient facilities to use to report erroneous surgeries.
Append one of the following HCPCS Level II modifiers to all lines related to the surgical error:
PA – Surgery wrong body part
PB – Surgery wrong patient
PC – Wrong surgery on patient
For hospital inpatient claims, append one of the following modifiers to all lines related to the surgical error:
MX – Wrong surgery on patient
MY – Surgery on wrong body part
MZ – Surgery on wrong patient
Read CMS Transmittal 1755, Change Request (CR) 6405 for more information regarding new benefits and claims processing policies. Refer to CMS Transmittal 101, CR 6405 for changes made to Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Sections 90-160.26.