CMS Issues Three National Coverage Determinations To Protect Patients From Preventable Surgical Errors

Main Category: Medicare / Medicaid / SCHIP
Article Date: 18 Jan 2009 - 1:00 PDT

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The Centers for Medicare & Medicaid Services (CMS) announced three national coverage determinations (NCDs) to establish uniform national policies that will prevent Medicare from paying for certain serious, preventable errors in medical care.

The following errors, called "never events," covered in these NCDs are identified in the National Quality Forum's (NQF) list of Serious Reportable Events:

- Wrong surgical or other invasive procedures performed on a patient;
- Surgical or other invasive procedures performed on the wrong body part; and
- Surgical or other invasive procedures performed on the wrong patient.
In addition, consistent with current policy for non-covered services, Medicare does not cover any services related to these non-covered services.

"The national coverage policies for certain types of surgical errors are important steps for Medicare in working to reduce or eliminate their occurrence and their associated payments." said CMS Acting Administrator Kerry Weems. "These policies have the potential to reduce causes of serious illness or deaths to beneficiaries and reduce unnecessary costs to Medicare."

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 NQF created a list of 27 never events, which was expanded to 28 events in 2006.

As part of the ongoing implementation of Section 5001(c) of the Deficit Reduction Act (DRA) of 2005, CMS has addressed some of the NQF never events through the Hospital-Acquired Conditions (HACs) provisions in the Inpatient Prospective Payment System (IPPS) final rule for fiscal years (FY) 2008 and 2009.

For discharges occurring on or after Oct. 1, 2008, Medicare will no longer pay a hospital at a higher rate for an inpatient hospital stay if the sole reason for the enhanced payment is one of the selected HACs, and the condition was acquired during the hospital stay. CMS is exploring the feasibility of adapting this policy to its other payment systems.

In the IPPS FY 2008 final rule, CMS selected eight categories of conditions for the HAC list, a number of which were among the 28 never events listed by the NQF and include retained foreign object after surgery, air embolism, blood incompatibility, stage III & IV pressure ulcers, and injuries related to falls and traumatic events such as electric shock and burns.

In the IPPS FY 2009 final rule, CMS added manifestations of poor glycemic control, including hypoglycemic coma, to the list. Hypoglycemic coma is closely related to NQF's listing of death or serious disability associated with hypoglycemia.

CMS determined that not all conditions included on the NQF list of Never Events should be addressed by the HAC payment provision and therefore determined that the NCD process was appropriate to address coverage for the three types of surgical errors cited above. Unlike the HAC provisions, which affect only payments to hospitals for inpatient stays, these NCDs may affect payment to hospitals, physicians, and any other health care providers and suppliers involved in the erroneous surgeries.

These NCDs are effective immediately, however; implementation instructions for processing such claims will occur at a later date. To view the NCDs, visit:

Wrong body part
Wrong patient
Wrong surgery performed on a patient

Centers for Medicare & Medicaid Services

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