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

Certified Inpatient Coder CIC

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.

4 Responses to “New Policy, Modifiers for Never Events”

  1. k-jag says:

    If I understand this transmittal correctly, lets say Surgeon A performs a mastectomy on the wrong side and the patient seeks the correct treatment from Surgeon B at a later setting, Surgeon B will will not be able to collect payment from Medicare or the patient, since CMS states they can’t foresee any way that an ABN or HINN can meet criteria in these cases. Why would any surgeon be willing to treat a patient in this scenario for free? I think this decision by CMS would further hurt a patient who has already been traumatized by a bad situation.

  2. Deby Bacorn says:

    I have tried to validate the MX, MY and MZ “modifiers” on the CMS website. It appears these codes are not modifiers but are surgical error codes appended by the payer once the claim data is added to the surgical errors list. Please confirm. Per Transmittal 1755 mentioned above:
    Once the claim data is added to the surgical errors list, contractors shall append one of the following applicable surgical error (payer- only) condition codes to the claim related to the surgical error.

    MX: Wrong Surgery on Patient

    MY: Surgery Wrong Body Part

    MZ: Surgery Wrong Patient

  3. Cindy Scott says:

    My understanding of this is if a patient is admitted into the hospital for (Example) a knee replacement and the surgery is performed on the wrong knee, none of the doctor’s involved in that surgery or care of the patient during the hospital stay will be paid during that visit. Why should they be? The patient is going to have to endure another surgery to fix the correct knee. The doctor’s(and hospital) should be bending over backwards for this patient. If you briing your car to the shop and they replace the wrong part, you do not pay the mechanic for his time or for the part or for the storage of your car.

  4. Tom Kennett says:

    Bizaroo. If it is true that following hospital discharge any reasonable and necessary services are covered regardless of whether they are or are not related to the surgical error, then (highly unlikely but…) you have a situation where a doctor would not be paid (repairing a lateral meniscus tear but wrong knee) and then turn around and get paid for lateral meniscus tear on the other knee and treating the knee originally operated on in error. Or did I read it incorrectly? I twist wrenches for a living, not knees.

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