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Effective Date: 01/01/2010 |
Title: Never Events
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Revision Date: 10/01/2015
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Document: BI252:00
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CPT Code(s): Y65.51-Y65.53
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above Revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
NEVER EVENTS
QualChoice
will not make payments for never events and will hold members harmless for these
costs.
1)
The National
Quality Forum (NQF) defines “Never Events” as “errors in medical care that are:
a)
clearly identifiable, preventable,
b)
serious in their consequences for patients, and
c)
that indicate a real problem in the safety and credibility of a health care
facility”
2)
Never Events
include wrong procedures, procedures on the wrong side, wrong body part or wrong
person.
3)
These events
are considered not medically necessary.
4)
This action
is done to more closely align QualChoice policy with the Centers for Medicare
and Medicaid (CMS) policy.
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Medical Statement
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NEVER EVENTS
In an effort
to more closely align QualChoice policy with CMS guidelines, QualChoice will not
make payments to providers for never events and will hold members harmless for
these costs.
1)
The National
Quality Forum (NQF) defines “Never Events” as “errors in medical care that are:
a)
Clearly identifiable, preventable, and serious in their consequences for
patients, and that indicate a real problem in the safety and credibility of a
health care facility”
b)
Never Events include wrong procedures, procedures on the wrong side,
wrong body part or wrong person.
2)
These never
events are not medically necessary as they are not required to diagnose or treat
an illness, injury, disease or its symptoms and are not consistent with
generally accepted standards of medical practice.
ICD-10 Codes Used In This BI:
Y65.51 Performance of wrong operation (procedure) on correct patient
Y65.52 Performance of operation (procedure) on patient not scheduled
for surgery
Y65.53 Performance of correct operation (procedure) on wrong side/body
part
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Background
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Wrong-side,
wrong-site, wrong-procedure, and wrong person adverse events (WSPEs) are
devastating, unacceptable, and often result in litigation. WSPEs are likely more
common than is generally realized.
Beginning in
July 2004, Joint Commission-accredited hospitals were required to adhere to the
Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person
Surgery by implementing time outs and site verifications for all invasive
procedures (Norton E., 2007). Higher-level policies or programs have been
implemented by the American Academy of Orthopedic Surgery, Joint Commission on
Accreditation of Healthcare Organizations, Veteran’s Health Administration,
Canadian Orthopedic, and the North American Spine Society Associations to reduce
wrong site surgery. (Michaels RK, et. al., 2006)
Seiden and
Barah (2006) published an analysis of several databases that demonstrated that
Never Events occur across all specialties, with high numbers noted in orthopedic
and dental surgery. Databases analyzed included: (1) the National Practitioner
Data Bank (NPDB), (2) the Florida Code 15 mandatory reporting system, (3) the
American Society of Anesthesiologists (ASA) Closed Claims Project database, and
(4) a novel Web based system for collecting WSPE cases (http://www.wrong-side.org).
Results showed that the NPDB recorded 5940 Never Events (2217 wrong-side
surgical procedures and 3723 wrong-treatment/wrong-procedure errors) in 13
years. Florida Code 15 occurrences of WSPEs number 494 since 1991, averaging 75
events per year since 2000. The ASA Closed Claims Project has recorded 54 cases
of WSPEs. Analysis of WSPE cases, including WSPE cases submitted to http://www.wrong-side.org,
suggest several common causes of WSPEs and recurrent systemic failures. Based on
these findings, they estimated that there are 1300 to 2700 WSPEs annually in the
United States. Despite a significant number of cases, they noted that reporting
of WSPEs is virtually nonexistent, with reports in the lay press far more common
than reports in the medical literature. Research suggests clear factors that
contribute to the occurrence of WSPEs, as well as ways to reduce them. They
concluded that wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse
events, although rare, are more common than health care providers and patients
appreciate. Prevention of WSPEs requires new and innovative technologies,
reporting of case occurrence, and learning from successful safety initiatives
(such as in transfusion medicine and other high-risk nonmedical industries),
while reducing the shame associated with these events.
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Reference
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1)
ICD-9 CM
Official Guidelines for Coding and Reporting Pages 92-105 at
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf
2)
CMS Hospital
Acquired Conditions – Trauma Code Descriptions at:
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalAcqConTraumaCodes.pdf
3)
National
Quality Forum Updates Endorsement of Serious Medical Events in Healthcare at:
http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
4)
National
Quality Forum website, at:
http://www.qualityforum.org/projects/completed/sre/
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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