Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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


Background

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.


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.
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