Medical Policy

Effective Date:01/01/2010	Title:Never Events
Revision Date:10/01/2015	Document:BI252:00
CPT Code(s):Y65.51-Y65.53
Public Statement
*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.
Medical Statement
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
Limits
Intentially left empty
Reference
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/
Application to Products
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.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.