CMS Pub. 100-04, ch. 32, § 220.4

Providers are liable for charges if TIPS is used in surgery, unless the beneficiary was

informed that he/she would be financially responsible prior to performance of the procedure.

To avoid this liability the provider should have the beneficiary sign an ABN.

230 – Billing 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

(Rev. 2998, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10)

The Centers for Medicare & Medicaid Services (CMS) internally generated a request for a

national coverage analysis (NCA) to establish national coverage determinations (NCDs)

addressing Medicare coverage of 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. Information

regarding these NCDs can be found in Publication (Pub.) 100-03, Chapter 1, sections 140.6,

140.7, and 140.8, respectively.

Inpatient Claims

Hospitals are required to bill two claims when a surgical error is reported and a covered

service is also being reported:

• One claim with covered service(s)/procedure(s) unrelated to the erroneous surgery(s)

on a Type of Bill (TOB) 11X (with the exception of 110), and

• The other claim with the non-covered service(s)/procedure(s) related to the erroneous

surgery(s) on a TOB 110 (no-pay claim)

NOTE: Both the covered and non-covered claim shall have a matching Statement Covers

Period.

For discharges prior to October 1, 2009, the non-covered TOB 110 must indicate on the 837

institutional claim format, or in the Remarks field of the Form CMS1450 one of the

applicable erroneous surgery(s) two-digit codes (entered exactly as specified below):

• For a wrong surgery on patient, enter the following: MX

• For a surgery on a wrong body part, enter the following: MY

• For a surgery on wrong patient, enter the following: MZ

For discharges on or after October 1, 2009, the non-covered TOB 110 must have one of the

following diagnosis codes reported in diagnosis position 2-9, instead of billing the

aforementioned two-digit codes in Remarks:

If ICD-9-CM Is Applicable

• E876.5 - Performance of wrong operation (procedure) on correct patient (existing

code)

• E876.6 - Performance of operation (procedure) on patient not scheduled for surgery

• E876.7- Performance of correct operation (procedure) on wrong side/body part

NOTE: The above codes shall not be reported in the External Cause of Injury (E-code)

field.

If ICD-10-CM Is Applicable

• Y65.51 Performance of wrong procedure (operation) on correct patient

• Y65.52 Performance of procedure (operation) on patient not scheduled for surgery

• Y65.53 Performance of correct procedure (operation) on wrong side of body parts

Outpatient, Ambulatory Surgical Centers, and Practitioner Claims

Providers are required to append one of the following applicable HCPCS modifiers to all lines

related to the erroneous surgery(s):

• PA: Surgery Wrong Body Part

• PB: Surgery Wrong Patient

• PC: Wrong Surgery on Patient

All claims

Claim/Lines submitted with a surgical error will be denied/line-item denied using the

following:

Medicare Summary Notice

23.17 – Medicare won’t cover these services because they are not considered medically

necessary.”

23.17 – Medicare no cubrirá estos servicios porque no son considerados necesarios por

razones médicas.

Claim Adjustment Reason Code

CARC 50 – These are non-covered services because this is not deemed a ‘medical necessity”

by the payer.

Group Code

CO – Contractual Obligation

Beneficiary Liability

Generally, beneficiary liability notices such an Advance Beneficiary Notice of Non-coverage

(ABN) or a Hospital Issued Notice of Non-coverage (HINN) is appropriate when a provider is

furnishing an item or service that the provider reasonably believes Medicare will not cover on

the basis of §1862(a)(1). An ABN must include all of the elements described in Pub. 100-04,

Claims Processing Manual (CPM), Ch. 30, §50.6.3, in order to be considered valid. For

example, the ABN must specifically describe the item or service expected to be denied (e.g. a

left leg amputation) and must include a cost estimate for the non-covered item or service.

Similarly, HINNs must specifically describe the item or service expected to be denied (e.g. a

left leg amputation) and must include all of the elements described in the instructions found in

the CPM Ch. 3,0 §200. Thus, a provider cannot shift financial liability for the non-covered

services to the beneficiary, unless the ABN or the HINN satisfies all of the applicable

requirements in the CPM Ch. 30, §50.6.3 and §200, respectively. Given these requirements,

CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these

NCD cases. However, an ABN or a HINN could be validly delivered prior to furnishing

services related to the follow-up care for the non-covered surgical error that would not be

considered a related service to the non-covered surgical error.