National Coverage Analysis (NCA) Tracking Sheet

Wrong Surgery Performed on a Patient



In 2002, prompted in part by the release of the 1999 Institute of Medicine report titled “To Err is Human: Building a Safer Health System,” the National Quality Forum (NQF) created a list of 27 Never Events which was expanded to 28 events in 2006. The NQF defines Never Events as errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients.  Included in the list of Never Events as a Surgical Event, is wrong surgery performed on a patient.

Medicare beneficiaries experience serious injury and/or death due to wrong surgeries performed on patients and additional costs are incurred by Medicare in order to correct adverse outcomes resulting from these errors. In order to address and reduce the occurrence of these surgeries CMS has decided to internally generate a national coverage analysis (NCA) to develop a national coverage determination (NCD) regarding coverage and payment for wrong surgeries performed on patients.

Benefit Category

No Benefit Category

Requestor Information

Requestor Name Requestor Letter
Internally generated N/A

Important Dates

Formal Request Accepted and Review Initiated
Expected NCA Completion Date
Public Comment Period
07/31/2008 - 08/30/2008
Proposed Decision Memo Due Date
Proposed Decision Memo Released
Proposed Decision Memo Public Comment Period
12/02/2008 - 01/01/2009
Decision Memo Released
Comments for this NCA
View Public Comments


Lead Analysts
Sarah Fulton, MHS
Lead Medical Officers
Madeline Ulrich MD, MS

Medicare Benefit Category Determination Date

Actions Taken

July 31, 2008

Opened an internally generated NCD addressing coverage for wrong surgeries performed on patients.

December 2, 2008

Proposed decision memo posted and 30-day public comment period begins.

January 15, 2009