Diagnostic Tests (other)
Federally Qualified Health Center Services
Home Health Services
Inpatient Hospital Services
Outpatient Hospital Services Incident to a Physician's Service
Rural Health Clinic Services
Skilled Nursing Facility
This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
In 2002, the National Quality Forum (NQF) published “Serious Reportable Events in Healthcare: A Consensus Report” 2, which listed 27 adverse events that were “serious, largely preventable and of concern to both the public and health care providers.” These events and subsequent revisions to the list became known as “never events.” This concept and need for the proposed reporting led to NQF’s “Consensus Standards Maintenance Committee on Serious Reportable Events,” which maintains and updates the list which currently contains 28 items. Among surgical events on the list is “Surgery performed on the wrong body part.” Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.
Indications and Limitations of Coverage
B. Nationally Covered Indications
C. Nationally Non-Covered Indications
The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs the procedure on the wrong body part because that particular surgical or other invasive procedure is not a reasonable and necessary treatment for the Medicare beneficiary’s particular medical condition.
A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location of the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine). Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision. Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).
Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice. Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation. They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization. They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar. They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.
(NCD last reviewed January 2009.)
Claims Processing Instructions