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Px performed on the wrong sode of the body

  1. Question Px performed on the wrong side of the body
    Medical Coding Books

    An MD performed a Px on the wrong side of the body , realized it when the patient was in the recovery room, and with the patient's consent, took the patient back to the OR to perform the Px on the correct side of the body.

    1. Would only the intended Px be coded?
    2. Is anything coded to document the error?

    Please include rationale or references.

    Last edited by sleepycats; 02-15-2009 at 07:27 AM.

  2. #2
    Hartford, CT
    This happened to a physician I worked for once. He decided not to charge for either procedure (the hospital didn't charge either). Of course it's entirely up to the doctor, but if it was his error, I don't think he should charge for the incorrect procedure at all. If it was a procedure that had to have pre-certification the insurance company probably wouldn't pay for the 2nd procedure anyway. There are now protocols inplace at the hospital my doc worked at to help revent this type of thing, when the patient comes in to the holding area he/she is given a marking pen and asked to make a arrow on the correct body part. After anesthesia is induced, there is a time-out called and the records are checked to verify the correct body part and side.

    Doreen, CPC

  3. #3
    Default never events
    If you take a look at CMS website, there is something called never events. These are for procedures performed on the wrong patient, wrong side of body, wrong body part etc. Should have never happened. This will tell you what has to be done. I believe the hospital has to report it, but I don't believe anyone charges for it.

  4. Default
    Great information!! Thanks for your help.

  5. #5
    Default never events
    No problem. Glad I could help!

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