Notification



Notification Issue Date:



Claim Payment Policy


Title:Never Events and Preventable Adverse Events

Policy #:00.01.44h

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

NEVER EVENTS

The Company does not reimburse facilities or professional providers for events that should never occur in a facility environment (i.e., a Never Event). Professional providers are those who are involved in surgical procedures including, but not limited to: operating surgeon, surgical assistants, and anesthesiologist.

Members are held harmless in the case of a Never Event; therefore, participating providers are not permitted to seek reimbursement from the member in any form (including copayments, deductibles, or coinsurance).

PREVENTABLE ADVERSE EVENTS

The Company does not reimburse facilities for the increased incremental costs of inpatient care that result when an individual is harmed by one of the Preventable Adverse Events listed below.

The Company does not reimburse professional providers for services directly related to any of the Preventable Adverse Events listed below when all the criteria for a Preventable Adverse Event are met as defined in this policy.

Members are held harmless in the case of a Preventable Adverse Event; therefore, participating providers are not permitted to seek reimbursement from the member in any form (including copayments, deductibles, or coinsurance).

It is understood that for the purpose of this policy, a Preventable Adverse Event is limited to the following conditions only when the condition also meets the definition of a Preventable Adverse Event as defined in the description section of this policy.


1.Foreign object (e.g., sponge, needle) that is inadvertently left in a patient after surgery

2.Air embolism: an air bubble that enters the blood stream and can obstruct the flow of blood to the brain and vital organs
3.Transfusion with the wrong type of blood
4.Severe pressure ulcers: deterioration of the skin due to the patient staying in one position too long that has progressed to the point that tissue under the skin is affected (Stage III), or that has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints (Stage IV)
5.Certain falls and trauma that occur in the facility and result in:
  • Fracture
  • Joint dislocation
  • Head injury
  • Crushing injury
  • Burn
  • Electric shock

6.Catheter-associated urinary tract infection (UTI)
7.Vascular catheter-associated infection
8.Manifestations of poor control of blood sugar levels, including the following:
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
9.Surgical site infection following coronary artery bypass graft (CABG) including a sternal wound infection
10.Surgical site infection following certain orthopedic procedures including the following:
  • Spine
  • Neck
  • Shoulder
  • Elbow
11.Surgical site infection following cardiac implantable electronic device (CIED) procedures
12.Surgical site infection following bariatric surgery for obesity including the following:
  • Laproscopic gastroenterostomy
  • Gastorenterostomy
  • Laproscopic gastric restrictive surgery
13.Iatrogenic pneumothorax with venous catheterization
14.Deep vein thrombosis (a blood clot in a major vein) and/or pulmonary embolism (blockage in the lungs) following certain orthopedic procedures including the following:
  • Total knee replacement
  • Hip replacement

The above conditions are considered reasonably preventable through the application of evidence-based protocols. There may be instances when one of these adverse conditions occurs despite adherence to nationally recognized standards of care. An adverse condition that occurs despite documented adherence to nationally recognized standards of care may not meet the criteria of a Preventable Adverse Event and, therefore, may be eligible for reimbursement consideration.

When a retrospective medical record review substantiates a Never Event or a Preventable Adverse Event as defined in this policy, reimbursement will be denied or adjusted accordingly.

EXCEPTION FOR REIMBURSEMENT

Subsequent services resulting from a Never Event or a Preventable Adverse Event rendered by a facility and/or professional provider not involved with the initial Never Event or Preventable Adverse Event will be eligible for reimbursement consideration.

REPORTING REQUIREMENTS

In addition to the reporting requirements of state, accrediting organizations, and participating provider contractual requirements, facilities and/or professional providers must report the Never Event or Preventable Adverse Event to the Company by completing the form in Attachment D or providing the following information to the reporting address listed on the Attachment D form:

1. Member name and member ID number

2. A description of the event

3. Dates of services and occurrence of the event

4. Attending physician(s)

5. Facility

REQUIRED DOCUMENTATION

The Company may require the submission of clinical information before or after the processing of a claim for services rendered to members.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

Guidelines

As part of the Company's Quality Management Program, the Company may request additional medical records for facility admissions with Never Events and Preventable Adverse Events.

This policy is consistent with the prevailing recommendations of the Centers for Medicare and Medicaid Services (CMS), the Leapfrog Group, Pennsylvania House Bill Number 84, New Jersey Act No. 2471, and the Joint Commission on the Accreditation of Healthcare Organizations. As of the date of this policy, this is the prevailing list of Never Events and Preventable Adverse Events that are subject to enforcement by CMS; however, the Company reserves the right to revise this list at any time with appropriate notice.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

In 1998, a group of employers (the Leapfrog Group) came together to discuss how they could use their influence to positively impact the quality and affordability of healthcare. A 1999 report by the Institute of Medicine gave the Leapfrog founders an initial focus: reducing preventable medical mistakes. The report found that up to 98,000 Americans die every year from preventable medical errors made in hospitals. The founders realized that they could take "leaps" forward with their employees, retirees, and families by rewarding hospitals that implement significant improvements in quality and safety. The Leapfrog Group was officially launched in November 2000.

In 2002, the National Quality Forum (NQF), a private organization whose members include the American Medical Association (AMA), created and endorsed a list of "serious reportable events" in reference to medical errors that should never occur in a facility. These 27 events included injuries caused by errors in medical management, errors in surgical management, and errors that occurred as a result of failure to follow standards of care or hospital policies and procedures. Importantly, these 27 events were identified by the NQF as both serious and preventable. The list of events represented a consensus among representatives of all parts of the healthcare system, including physicians, hospitals, and other professional providers; public and private purchasers of healthcare; consumers; accrediting boards; and those involved in healthcare research and/or quality improvement. The list was expanded in 2006 to include a combination of 28 “Never Events” and “Preventable Adverse Events.”

Using the criteria developed by the National Quality Forum (NQF), and working with other groups, the Centers for Medicare and Medicaid Services (CMS) issued new Medicare and Medicaid payment and coverage policies to improve safety for hospitalized patients.

In 2007, CMS issued a final rule to end additional payments to hospitals for certain preventable conditions acquired during a hospital stay (i.e., Hospital-Acquired Conditions [HAC]). The CMS rule also prohibits passing these charges on to patients. The CMS selection criteria for HAC and the NQF selection criteria are similar, but not identical. Over time, CMS has published subsequent fiscal year final rules that have expanded the list of selected HACs that have Medicare payment implications.

In 2009, CMS initiated three Medicare National Coverage Determinations (NCD) to address “wrong surgery,” a category of “never events” included in the NQF’s list of Serious Reportable Adverse Events. These three CMS NCDs address coverage for surgery on the wrong body part, surgery on the wrong patient, and wrong surgery performed on a patient.

The National Quality Forum’s (NQF) list of “Never Events” and “Preventable Adverse Events” has triggered a number of quality initiatives in an effort to encourage healthcare providers to improve patient safety and reduce avoidable errors.

NEVER EVENT

For purposes of this policy, a Never Event is defined as any of the following:

(1)A surgical or other invasive procedure performed in a facility on the wrong body part/wrong site

(2)

A surgical or other invasive procedure performed in a facility on the wrong patient

(3)

The wrong surgical or other invasive procedure performed on a patient in a facility

PREVENTABLE ADVERSE EVENT

For purposes of this policy, a Preventable Adverse Event is defined as an event that meets all of the following criteria:

(1)Be reasonably preventable through the use of evidence-based guidelines and/or criteria

(2)

Be within the control of the facility or the providers practicing in the facility

(3)

Be the result of an error made in the facility (i.e., the condition was not present when the patient was admitted to the facility)

(4)

Result in serious or significant harm

(5)

Be clearly, unambiguously, and precisely identified, reportable, and measurable

For purposes of this policy, a facility is defined as a short-term or long-term, duly licensed acute care, general hospital, or a duly licensed pediatric or cancer hospital, an ambulatory surgical center (ASC), or a skilled nursing facility. For purposes of this policy, a facility does not include any of the following: nursing home; custodial care home; health resort, spa or sanitarium; place for rest; place for aged; place for treatment of mental illness; place for treatment of alcohol or drug abuse; place for treatment of pulmonary tuberculosis; or place for provision of hospice care.

MANDATES

PENNSYLVANIA HOUSE BILL NUMBER 84
Effective August 9, 2009, Pennsylvania House Bill Number 84, the Preventable Serious Adverse Events Act, defines language associated with preventable serious adverse events. This bill states: "A healthcare provider may not knowingly seek payment from a health payer or patient for a preventable serious adverse event or for any services required to correct or treat the problem created by a preventable serious adverse event when that event occurred under their control."

NEW JERSEY ACT NO. 2471
Effective February 27, 2010, New Jersey Act No. 2471 prohibits hospitals from seeking payment for costs associated with conditions or events that are subject to the hospital-acquired condition payment provisions of the Medicare program, as regulated by the Centers for Medicare and Medicaid Services (CMS).

For additional state mandate information, refer to Attachments B and C of this policy.

References

Agency for Healthcare Research and Quality (AHRQ). Patient safety primers. Never events. [AHRQ Web site]. October 2012. Available at: http://psnet.ahrq.gov/primer.aspx?primerID=3. Accessed September 15, 2015.


Centers for Medicare & Medicaid Services (CMS). Fact Sheets. Details for: CMS improves patient safety for Medicare and Medicaid by addressing Never Events. [CMS Web site]. 08/04/08. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3224&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). Fact Sheets. Details for: Medicare takes new steps to help make your hospital stay safer. [CMS Web site]. 08/04/08. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3227&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). Hospital acquired conditions. [CMS Web site]. 2013. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). Medicare & Medicaid Research Review (MMRR). Enhancing Medicare's hospital-acquired conditions policy to encompass readmissions. [CMS Web site]. 2012. Available at: http://www.cms.gov/mmrr/mmrr-2012-02.html. Accessed September 15, 2015.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 140.7: Surgical or other invasive procedure performed on the wrong body part. [CMS Web site]. 07/06/09. Available at:http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=328&ncdver=1&DocID=140.7&bc=gAAAABAAAAAA&. Accessed September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).140.8: Surgical or other invasive procedure performed on the wrong patient. [CMS Web site]. 01/15/09. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=329&ncdver=1&DocID=140.8&bc=gAAAABAAAAAA&. Accessed September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 140.6: Wrong surgical or other invasive procedure performed on a patient. [CMS Web site]. 01/15/09. Available at:http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=327&ncdver=1&DocID=140.6&bc=gAAAABAAAAAA&. Accessed September 15, 2015.

Centers for Medicare & Medicaid Services (CMS). The Centers for Medicare & Medicaid Services' Office of Research, Development, and Information (ORDI). Evidence-based guidelines for selected and previously considered hospital-acquired conditions. [CMS Web site]. 01/05/2011. Available at:http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/LaBresh_EB-GL-HAC-2010.pdf. Accessed September 15, 2015.

General Assembly of Pennsylvania. Pennsylvania House Bill No. 84. Preventable Serious Adverse Events Act. [PA State Legislature Web site]. 06/01/09. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2009&sessInd=0&billBody=H&billTyp=B&billNbr=0084&pn=1955. Accessed September 15, 2015.

Leapfrog Group. Leapfrog Group position statement on never events. [Leapfrog Group Web site]. Available at: http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_quality_and_safety_survey_copy/never_events. Accessed September 15, 2015.

National Quality Forum (NQF). Fact Sheet: Serious reportable events transparency & accountability are critical to reducing medical errors. [NQF Web Site]. Available at: http://www.qualityforum.org/projects/completed/sre/fact-sheet.asp. Accessed September 15, 2015.

Senate Committee Substitute for SENATE, No. 2471. State of New Jersey 213 Legislature. An Act concerning patient safety and supplementing Title 26 of the Revised Statutes. [State of New Jersey Web site]. 01/26/2009. Available at:http://www.google.com/url?url=http://www.njslom.org/documents/enacted-legislation-summary.pdf&rct=j&frm=1&q=&esrc=s&sa=U&ei=KVgcVNueLY2lyATGp4GgCw&ved=0CB8QFjAC&sig2=5Bv_aoGfOY5s5bBa2EFLOA&usg=AFQjCNHCJRNh89GhhnxlHUNDQivFgMMKDQ. Accessed September 15, 2015.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

PA Surgery Wrong Body Part
PB Surgery Wrong Patient
PC Wrong Surgery on Patient


Coding and Billing Requirements


Cross References

Attachment A: Never Events and Preventable Adverse Events
Description: Appendix I Hospital Acquired Conditions (HACS) List

Attachment B: Never Events and Preventable Adverse Events
Description: Pennsylvania House Bill No. 84 addressing Never Events and Preventable Adverse Events

Attachment C: Never Events and Preventable Adverse Events
Description: New Jersey Act No. 2471

Attachment D: Never Events and Preventable Adverse Events
Description: Never Event or Preventable Adverse Event Reporting Form



Policy History

Revisions from 00.01.44h
10/01/2018This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to the policy:

T81.40XA: Infection following a procedure, unspecified, initial encounter

T81.41XA: Infection following a procedure, superficial incisional surgical site, initial encounter

T81.42XA: Infection following a procedure, deep incisional surgical site, initial encounter

T81.43XA: Infection following a procedure, organ and space surgical site, initial encounter

T81.44XA: Sepsis following a procedure, initial encounter

T81.49XA: Infection following a procedure, other surgical site, initial encounter

This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM code has been termed from the policy:

T81.4XXA: Infection following a procedure, initial encounter

This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM narratives have been revised in this policy:

S62.626B

FROM: Displaced fracture of medial phalanx of right little finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of right little finger, initial encounter for open fracture

S62.627B

FROM: Displaced fracture of medial phalanx of left little finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of left little finger, initial encounter for open fracture

S62.628B

FROM: Displaced fracture of medial phalanx of other finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of other finger, initial encounter for open fracture

S62.629B

FROM: Displaced fracture of medial phalanx of unspecified finger, initial encounter for open fracture

TO: Displaced fracture of middle phalanx of unspecified finger, initial encounter for open fracture

S62.654B

FROM: Nondisplaced fracture of medial phalanx of right ring finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of right ring finger, initial encounter for open fracture

S62.655B

FROM: Nondisplaced fracture of medial phalanx of left ring finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of left ring finger, initial encounter for open fracture

S62.656B

FROM: Nondisplaced fracture of medial phalanx of right little finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of right little finger, initial encounter for open fracture

S62.657B

FROM: Nondisplaced fracture of medial phalanx of left little finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of left little finger, initial encounter for open fracture

S62.658B

FROM: Nondisplaced fracture of medial phalanx of other finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of other finger, initial encounter for open fracture

S62.659B

FROM: Nondisplaced fracture of medial phalanx of unspecified finger, initial encounter for open fracture

TO: Nondisplaced fracture of middle phalanx of unspecified finger, initial encounter for open fracture


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.