CMS Proposes No-Pay Policies for 3 Preventable Surgical Errors

CMS has proposed today three national coverage determinations (NCDs) to establish uniform national policies that would prevent Medicare from paying for certain serious, preventable errors, or "never events," identified in the National Quality Forum's (NQF's) 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 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 of 2005, CMS has addressed some of the NQF Never Events through the Hospital-Acquired Conditions (HACs) provisions in the Inpatient Prospective Payment System final rule for fiscal years 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 how to adapt this policy to its other payment systems.

In the IPPS FY 2008 final rule, CMS selected eight conditions for the HAC list, a number of which were among the 28 NQF Never Events and include retained foreign object after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, and falls and traumas 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 NQF Never Events can be adequately addressed via the HAC payment provision and therefore determined that the NCD process was more appropriate to address coverage for wrong-site, wrong-patient and wrong-procedure surgery. Unlike the HAC provisions, which affect only payments to hospitals for inpatient stays, the final NCDs could affect payment to hospitals, physicians and any other healthcare providers and suppliers involved in the erroneous surgeries.

CMS will accept comments from the public regarding the proposed coverage policies until January 1. Comments should be submitted separately for each of the NCDs. After the 30-day public comment period closes, CMS will issue final NCDs within 60 days. Learn more:

• wrong-site surgery;

• wrong-patient surgery;

• wrong surgery performed on a patient; and

• Proposed Decision Memo.