CurrentColorado Rocky Mountain Health PlansPolicy 2026R0117A

Wrong Surgical or Other Invasive Procedure Reimbursement

Defines UnitedHealthcare's reimbursement stance and claim reporting requirements when a surgical or other invasive procedure is performed erroneously (wrong procedure, wrong body part, or wrong patient); applies to services billed on CMS-1500 and UB04 and to UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWrong Surgical or Other Invasive Procedure Reimbursement

Policy CodePolicy 2026R0117A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionHospitals must submit a no-pay claim (Type of Bill 110) with the appropriate ICD-10-CM Y65.x diagnosis to identify the erroneous surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3error types not reimbursed

3HCPCS modifiers to report

3ICD-10-CM codes (Y65.x)

110hospital no-pay claim

allapplies to products

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Coverage Criteria — Wrong Surgical or Other Invasive Procedures

Coverage criteria for wrong surgeries

UnitedHealthcare will not reimburse for wrong surgical or other invasive procedures or related services when the error is one of the following:

ANY of the following

ALL of the following
- Different procedure performed (not the one intended)
ALL of the following
- Correct procedure performed on wrong body part
ALL of the following
- Correct procedure performed on wrong patient

Related services not reimbursed

All services provided in the operating room related to the error
All providers in the operating room when the error occurs (who could bill individually for their services)
All related services provided during the same hospitalization in which the error occurred

Related services that are excluded from the non‑reimbursement rules (i.e., may be reimbursed)

Services provided following hospital discharge, regardless of whether they are related to the surgical error
Performance of the correct procedure

Coding Identifiers and Billing Codes for Erroneous Surgery

ICD-10-CM Identifiers for Erroneous Surgical EventsICD-10Not Covered

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

HCPCS Modifiers for Erroneous Surgical EventsHCPCSNot Covered

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

Hospital no‑pay claim (Type of Bill)

Type of Bill110 (no-pay hospital claim to report all charges associated with the erroneous surgery)

When requiredSubmit a Type of Bill 110 for hospital inpatient claims that include an erroneous surgery; if unrelated services occur during same stay submit a separate claim for unrelated services

PurposeIdentify and report charges for the erroneous surgical procedure so costs are not reimbursed to the provider or billed to members

Provider Claim Reporting and Billing Actions

Billing Rule

Hospital no‑pay claim and ICD‑10‑CM reporting required

Hospitals must submit a no‑pay hospital inpatient claim (Type of Bill 110) that reports the erroneous procedure using one of the ICD‑10‑CM Y65.x codes (Y65.51, Y65.52, or Y65.53). If unrelated services occur during the same stay, submit two claims: one no‑pay Type of Bill 110 for the erroneous services and a separate claim for unrelated services.

Type of Bill required: 110 (no‑pay)
Report one of these ICD‑10‑CM codes on the no‑pay hospital claim: Y65.51, Y65.52, Y65.53
If non‑related services occur in the same stay, submit two claims — one no‑pay (110) with the Y65.x code(s) and one for unrelated services.

Definitions

Surgical or Other Invasive Procedures

DefinitionSurgical or Other Invasive Procedures are operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice; includes CPT surgery section and other invasive procedures (e.g., percutaneous transluminal angioplasty, cardiac catheterization) and minimally invasive procedures requiring entry into a body cavity; excludes use of instruments for examinations or very minor procedures.

Scope examplesIncludes biopsies, excisions, deep cryotherapy for malignant lesions, multi‑organ transplantation, catheter or probe placements requiring needle or trocar entry.

ExclusionsDoes not include non‑invasive examinations using instruments such as otoscopes or very minor procedures.

Wrong Surgical or Other Invasive Procedure Performed on a Patient

DefinitionA procedure that is not consistent with the correctly documented informed consent for that patient, including performance on the wrong patient, on the wrong body part (wrong side or wrong level), or performing a different procedure than intended; excludes emergent situations that preclude obtaining informed consent.