LCD/NCD Portal

NCD140.8

 

SURGICAL OR OTHER INVASIVE PROCEDURE PERFORMED ON THE WRONG PATIENT

 

 

Effective Date of this Version

• 7/6/2009

 

Benefit Category

• Diagnostic Tests (other).

• Federally Qualified Health Center Services.

• Home Health Services.

• Incident to a physician's professional Service.

• Inpatient Hospital Services.

• Outpatient Hospital Services Incident to a Physician's Service.

• Physicians' Services.

• Rural Health Clinic Services.

• Skilled Nursing Facility.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

 

General

• In 2002, the National Quality Forum (NQF) published “Serious Reportable Events in Healthcare: A Consensus Report” 3, 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 “Surgical procedure performed on the wrong patient.”

• 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

 

Nationally Covered Indications

• N/A

 

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 a procedure that was intended for a different patient on a Medicare beneficiary who does not need that procedure because it 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 patient if that procedure is not consistent with the correctly documented informed consent for that patient.

• 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.

o 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.

o 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.

o They do NOT include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.

D. Other

• N/A

 

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3http://www.qualityforum.org/pdf/reports/sre.pdf

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Claims Processing Instructions

• TN 1755 (Medicare Claims Processing)

• TN 1764 (Medicare Claims Processing)

• TN 1778 (Medicare Claims Processing)

• TN 1819 (Medicare Claims Processing)

 

Coverage Transmittal Link

http://www.cms.gov/transmittals/downloads/R102NCD.pdf

 

National Coverage Analyses (NCAs)

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with NCAs, from the National Coverage Analyses database.

o Original consideration for Surgery on the Wrong Patient (CAG-00403N)

 

 

Medicare NCD Link