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CMS Publishes New Modifiers for Outpatient Never Events, Clarifies Hospital
Acquired Conditions
June, 2009
Recently, CMS has introduced three new modifiers for use with never events
identified by the National Quality Forum (NQF). These went into effect January
1, 2009, as part of the list of valid modifiers. The new modifiers include the
following:
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PA for surgical or invasive procedure on the wrong body part;
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PB for surgical or invasive procedure on the wrong patient;
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PC for wrong surgery or invasive procedure on patient.
Three decision memos published by CMS earlier this year related to the never
events of wrong patient, wrong body part and wrong procedure surgeries and
invasive procedures. These memos discussed Medicare’s non-coverage of these
procedures, distinguishing them from Hospital Acquired Conditions (HACs) in the
inpatient environment, which remain covered.
For wrong patient, wrong body part, wrong procedure surgeries, the services are not
covered and should not be billed to Medicare as covered procedures. These services should EITHER not be billed at all to Medicare or billed
to Medicare as non-covered with the appropriate modifier (-PA, -PB or -PC) if
the circumstance requires a Medicare denial.
Because services related to HACs remain covered, these services are billed as
covered services on the inpatient claim.
Many providers assumed that HACs were non-covered conditions, and were therefore
surprised by the CMS decision. However, per CMS, the provision of the Deficit
Reduction Act requiring adoption of the HACs requires that the DRG assignment
not be higher because of the HAC, but does not specify that the HAC services
are non-covered. This decision highlights the difference between the CMS list
of HACs, which they have determined are “reasonably preventable” but not always
avoidable and the NQF’s never events which should not occur if proper practices
are adopted.
For additional information, please contact Charlene Nutter with The Quality
Management Consulting Group, Ltd. (QMCG) at 614.227.4852 /
cnutter@qmcg.com.
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