Commercial

Medical Policy

Notification

Never Events and Preventable Serious Adverse Events

Notification Issued Date: N/A

This 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

Policy Attachment

Attachment to Policy #

00.01.44j

Attachment:

Policy #:

00.01.44j

Description:

Never Event or Preventable Serious Adverse Event Reporting Form

Title:

Never Events and Preventable Serious Adverse Events

Never Events and Preventable Serious Adverse Events Reporting Form

Procedure for reporting Never Events and Preventable Serious Adverse Events to the Company.

1.	The participating facility will either send a letter on letterhead or use the attached form to report the event. If using letterhead, please include all the information on the form.
2.	Mail or fax the letter to Corporate and Financial Investigations Department (CFID).

Report of a Never Event or Preventable Serious Adverse Event
MEMBER NAME __________________________________	Member # __________________
Date of Birth ____________________ Age_____________	Gender: (circle) Female Male
Occurrence Date _________________________________	Date Reported _________________________
Reported by ____________________________________	Contact Phone # ________________________
Attending Physician(s)______________________________

Facility Name(s) (location of incident/concern)_____________________________________________

Facility Type (Hospital, Surgery Center, etc) _______________________________________________

SUMMARY OF EVENT

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Please send report under confidential cover to:
Independence Blue Cross
Corporate and Financial Investigations Department (CFID)
1901 Market Street
Philadelphia, PA 19103
or (fax) 215-567-6901

Version Effective Date:

12/05/2022

Version Issued Date:

12/05/2022

Version Reissued Date:

06/26/2024