CurrentHighmark Blueshield NenyPolicy N/A

Preventable Serious Adverse Events (PSAEs) / Never Events

Defines the Plan's reimbursement stance for preventable serious adverse events (PSAEs) including wrong surgery events and hospital-acquired conditions, and explains provider billing and member liability expectations for affected commercial and Medicare Advantage markets.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPreventable Serious Adverse Events (PSAEs) / Never Events

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 11, 2018

Next Review DateN/A

Key ActionDo not seek reimbursement for care directly related to a PSAE; submit a no-payment UB-04 Type of Bill 110 for inpatient non-covered services when a wrong surgical event occurs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2018-06-11Effective date

Held harmlessMember liability

No reimbursementProvider payment

PA/PB/PCOutpatient modifiers

Type 110Inpatient no-pay bill

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Coverage criteria and exclusions for PSAEs / HACs

Coverage stance and billing criteria — coverage exclusions and member liability provisions for PSAEs and HACs

Coverage exclusions and member liability provisions for PSAEs and HACs

The Plan will not reimburse or allow providers to retain reimbursement for any care directly related to a Preventable Serious Adverse Event (PSAE). The Member shall not be liable for payment for any care resulting from PSAEs.

Source: policy statement on noncoverage and member held harmless.

A provider may not knowingly seek payment from The Plan or from the member for a PSAE or for any services required to correct or treat problems created by a PSAE that occurred under the provider's control.

Providers must not bill for PSAE-related care.

All providers in the same group, employed by, or associated with the provider(s) who caused or created the PSAE or error, and who could bill or may receive reimbursement for services to correct the error, are not eligible for payment.

Group-affiliation exclusion applies to corrective services.

Subsequent services rendered by a provider not involved with the initial PSAE will be considered for reimbursement (subject to other policy rules).

Uninvolved providers' subsequent services may be reimbursed.

Providers must populate Present on Admission (POA) data on all inpatient claims to identify Hospital-Acquired Conditions (HACs); if payment is reduced because of a HAC, the provider may not seek payment from the member for the difference and the member must be held harmless.

POA reporting and member protection for HAC-related payment reductions.

Coverage and billing criteria for PSAEs — Plan will not reimburse services directly related to PSAEs; member held harmless; subsequent unrelated care guidance

The Plan will not reimburse services directly related to PSAEs or allow providers to retain payment; members are held harmless. Subsequent services by uninvolved providers may be reimbursed; providers associated with the event are not eligible.

Services directly related to a PSAE are not covered and providers may not retain reimbursement; the Member is not liable for payment.

Direct noncoverage and member held harmless.

If an outpatient PSAE (that would be classified as a HAC in the inpatient setting) is recognized before discharge, the facility should not submit a claim to The Plan and should not present a bill to the member.

Outpatient recognition before discharge — do not submit claim or bill member (Act 1).

If an outpatient PSAE is not recognized until after submission/payment, the provider should notify its Institutional Provider Relations representative so payment can be prevented or retracted; the Member must be held harmless.

Post-payment discovery — notify Institutional Provider Relations for retraction.

PSAE coverage rules — coverage and billing rules for PSAEs, WSEs, and HACs

Coverage and billing rules for PSAEs, WSEs, and HACs

The Plan will not reimburse for care directly related to PSAEs; members are held harmless and providers may not bill members for such care.

Overall reimbursement stance.

When a Wrong Surgical Event (WSE) occurs, all services provided in the operating room when the error occurs are considered related and therefore not covered.

OR services during WSE considered related and not covered.

All providers in the operating room when the error occurs who could bill individually are not eligible for payment; providers in the same group or associated with the responsible provider are also not eligible for payment for corrective services.

Provider eligibility exclusions for WSE-related services.

Outpatient/ASC/practitioner claims for WSEs: append HCPCS modifier PA (wrong body part), PB (wrong patient), or PC (wrong surgery) on each claim line; these lines will be denied as not covered and the member held harmless. If the outpatient PSAE is recognized prior to discharge, the facility should not submit a claim or bill the member; if recognized after payment, notify Institutional Provider Relations to retract payment.

PSAE coverage exclusions and procedures — exclusions and member protections for PSAEs and related HACs

Coverage exclusions and member protections for PSAEs and related HACs

No reimbursement will be provided for care directly related to a PSAE; the Member must not be held liable for payment of such care.

Denial of coverage for PSAE-related care and member protection.

All providers in the operating room when a wrong surgical error occurs who could bill individually are not eligible for payment; all providers in the same group as the responsible provider are not eligible for payment for corrective services.

Provider eligibility exclusions for WSE/HAC corrective services.

Outpatient claim lines related to Wrong Surgical Events must include HCPCS modifiers PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient), or PC (Wrong Surgery on Patient); these outpatient claim lines will be denied as not covered and the member held harmless. These modifiers are not applicable to inpatient submissions where specific diagnosis codes (MX, MY, MZ) are required on the no-payment claim.

Modifier requirement for outpatient claims and inpatient diagnosis code requirement.

Coding, modifiers, and POA reporting

Wrong surgical event modifiers and inpatient error codesHCPCS | mixedNot Covered

MX / MY / MZ	UB-04 Form Locator 81 surgical error codes for no-pay inpatient claims (MX - wrong surgery on patient; MY - wrong body part; MZ - wrong patient)
PA / PB / PC	HCPCS modifiers for outpatient/ASC/practitioner claims (PA: Surgery Wrong Body Part; PB: Surgery Wrong Patient; PC: Wrong Surgery on Patient)

Modifiers for wrong surgery eventsModifierNot Covered

Modifier PA	Surgery Wrong Body Part
Modifier PB	Surgery Wrong Patient
Modifier PC	Wrong Surgery on Patient
Modifier MX	UB-04 wrong surgery on patient (no-pay Form Locator 81 remark)
Modifier MY	UB-04 surgery on the wrong body part (no-pay Form Locator 81 remark)
Modifier MZ	UB-04 wrong patient (no-pay Form Locator 81 remark)

Wrong surgery modifiersModifierCovered

PA	Modifier — Surgery Wrong Body Part
PB	Modifier — Surgery Wrong Patient
PC	Modifier — Wrong Surgery on Patient
MX	Inpatient remark modifier — wrong surgery on patient (entered in Form Locator 81)
MY	Inpatient remark modifier — surgery on wrong body part (entered in Form Locator 81)
MZ	Inpatient remark modifier — surgery on wrong patient (entered in Form Locator 81)

WSE modifiers and inpatient error codesHCPCS | mixedNot Covered

PA	HCPCS modifier - Surgery Wrong Body Part
PB	HCPCS modifier - Surgery Wrong Patient
PC	HCPCS modifier - Wrong Surgery on Patient
MX	Inpatient diagnosis code designation for wrong surgery on patient (used on no-pay claim)
MY	Inpatient diagnosis code designation for surgery on the wrong body part (used on no-pay claim)
MZ	Inpatient diagnosis code designation for surgery on the wrong patient (used on no-pay claim)

Present on Admission population requirement

RequirementInpatient acute-care hospitals must populate Present on Admission (POA) data on all inpatient claims to identify hospital-acquired conditions and support HAC/PSAE determinations.

ScopeApplies to all inpatient acute-care hospitals, including critical access and children's inpatient facilities.

PurposePOA reporting prevents additional reimbursement when specified conditions occur during a stay but were not present at admission and ensures the member is held harmless for payment reductions.

Provider billing, claim submission, and notification actions

Billing Rule

Inpatient no-pay claim procedure and POA reporting

If a wrong surgical event occurs during an inpatient stay, the provider must submit a no-payment UB-04 Type of Bill 110 for the non-covered services that are directly related to the wrong surgical event. The appropriate diagnosis code identifying the nature of the medical error must be reported on the no-pay claim. Present on Admission (POA) data must be populated on all inpatient claims to support identification of conditions not present at admission.

Submit a no-payment claim (Type of Bill 110) for non-covered services related to the wrong surgical event.
If other services during the same stay are unrelated to the wrong surgical event, submit two separate claims using the same Statement Covers From and Through Dates: (1) Type of Bill 110 no-pay claim for the non-covered services and (2) an inpatient claim (Type of Bill 11X, excluding 110) for covered services.
Report the appropriate inpatient surgical error diagnosis code on the no-pay claim only.
Populate Present on Admission (POA) indicators on all inpatient claims per UB-04 requirements.

Key definitions

Preventable Serious Adverse Event (PSAE) — definition summary

TermPreventable Serious Adverse Event (PSAE)

DefinitionA serious, identifiable, and unambiguous occurrence or provider error that is preventable and should never occur; includes NQF-listed events and CMS-defined Hospital-Acquired Conditions.

ExamplesIncludes certain surgical infections, surgery on wrong body part, surgery on wrong patient, and wrong surgical procedure.

Wrong Surgical Event (WSE) — definition summary

TermWrong Surgical Event (WSE)

Core definitionA surgical or other invasive procedure performed erroneously when the practitioner performs the wrong procedure, on the wrong body part, or on the wrong patient (not consistent with correctly documented informed consent).

Policy Summary

PayerHighmark Blueshield Neny

PolicyPreventable Serious Adverse Events (PSAEs) / Never Events

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 11, 2018

Next Review DateN/A

Key ActionDo not seek reimbursement for care directly related to a PSAE; submit a no-payment UB-04 Type of Bill 110 for inpatient non-covered services when a wrong surgical event occurs.

SourceLink

On This Page

For wrong surgical events occurring during an inpatient stay submit a no-payment claim (Type of Bill 110) for the non-covered services with the appropriate diagnosis code; if other unrelated covered services occurred during the same stay submit a separate inpatient claim (Type 11X) using the same Statement Covers From/Through Dates.

Inpatient no-pay claim procedure and separate claim for unrelated covered services.

Providers must append applicable HCPCS modifiers (PA, PB, PC) on each outpatient/ASC/practitioner claim line related to a wrong surgical event; these claim lines will be denied as not covered and the member held harmless.

Outpatient modifier requirement for WSE claim lines.

It is not acceptable to refrain from submitting a claim because a PSAE occurred.

Claims submission policy: submit appropriate claims per rules.

Outpatient handling and modifier use; pre-/post-discovery actions.

Inpatient WSEs: submit a no-payment Type of Bill 110 for non-covered services with the appropriate diagnosis code identifying the medical error; if other unrelated covered services were provided during the same stay submit a separate inpatient claim (Type 11X) with identical statement dates.

Inpatient no-pay claim process for WSEs.

Hospitals must populate Present on Admission (POA) data on all inpatient claims to identify HACs; if payment is reduced because of a HAC, the provider may not seek payment from the member for the difference and the member must be held harmless.

POA requirement and member protection for HACs.

Exceptions

Emergent intraoperative situations where consent is not possible are not considered WSEs.
Intraoperative discoveries that reasonably justify an immediate change in plan (e.g., pathology near intended site, unusual anatomy) are not considered WSEs when risk of reoperation outweighs consultation.

Subsequent services required to treat or correct problems created by a HAC that appear on the NQF list are not eligible for payment by providers who caused the HAC; other CMS-recognized HACs not on the NQF list follow CMS rules, permitting billing of reasonable and necessary post-discharge services with the member held harmless except for normal cost-sharing.

Subsequent services handling for HACs per NQF/CMS distinctions.

For inpatient Wrong Surgical Events submit a no-payment claim (Type of Bill 110) for the non-covered services and report the appropriate surgical error code in Form Locator 81/remarks (MX for wrong surgery on patient; MY for surgery on wrong body part; MZ for wrong patient). If other covered services were provided in the same stay, submit a separate inpatient claim (Type 11X) for those services using identical statement dates.

Inpatient no-pay claim protocol including MX/MY/MZ codes and separate claim for covered services.

Providers are not permitted to seek payment for subsequent services required to treat or correct problems created by HACs that appear on the NQF list. For other CMS-recognized HACs not on the NQF list CMS rules apply and permit billing of reasonable and necessary post-discharge services; the member must be held harmless for corrective services except for normal cost-sharing amounts under the member's benefits.

HAC subsequent services and member cost-sharing guidance.

When an outpatient PSAE that is equivalent to a HAC in the inpatient setting is recognized before discharge the facility should not submit a claim or bill the member; if recognized after payment notify Institutional Provider Relations to retract payment.

Act 1 and outpatient HAC-equivalent handling and retraction process.

It is unacceptable to refrain from submitting a claim because a PSAE occurred; providers must follow the claim submission protocols described for outpatient and inpatient events.

Billing practice reminder.

Billing Rule

Outpatient / ASC / Practitioner claim modifiers for wrong surgery events

For outpatient facility, ASC, and practitioner claims for an erroneous surgery, providers must append the applicable HCPCS modifier on every claim line associated with the erroneous procedure. These modifiers will cause the claim lines to be denied as not covered and the member held harmless.

Append modifier PA for Surgery Wrong Body Part on each applicable outpatient/ASC/practitioner line.
Append modifier PB for Surgery Wrong Patient on each applicable outpatient/ASC/practitioner line.
Append modifier PC for Wrong Surgery on Patient on each applicable outpatient/ASC/practitioner line.
Note: These HCPCS modifiers are not used on inpatient claim submissions; inpatient reporting uses the specified diagnosis codes and inpatient no-pay claim procedure.

Denial Risk

Outpatient PSAE billing actions and member protection

When an outpatient preventable serious adverse event (PSAE) such as a wrong surgical event is recognized before the patient is discharged, the facility must not submit a claim to the Plan and must not bill the member — the member is held harmless. If the outpatient PSAE is not recognized until after submission or payment, the provider must notify its Institutional Provider Relations representative so payment can be prevented or retracted. If corrective services are subsequently required and the member chooses to receive them from the provider responsible for the PSAE, that provider may not seek payment from the Plan or the member for those corrective services.

If PSAE is recognized before discharge: do not submit a claim and do not bill the member.
If PSAE is recognized after claim submission/payment: notify Institutional Provider Relations to prevent or retract payment.
Providers responsible for the outpatient PSAE may not bill the Plan or the member for subsequent corrective services; the member must be held harmless.
Subsequent services provided by providers not involved in the initial PSAE may be considered for reimbursement per standard rules.

Claim identifiersOutpatient/ASC/practitioner claim lines must append HCPCS modifiers PA, PB, or PC to denote WSE-related lines; inpatient claims require specified diagnosis codes rather than these modifiers.

PSAE expanded definition — includes NQF-listed events and HACs

PSAE scopeIncludes NQF-listed serious reportable events and Hospital-Acquired Conditions (HACs) as defined by CMS; policy incorporates NQF and CMS definitions.

Coverage impactThe Plan will not reimburse for care directly related to PSAEs; providers may not retain reimbursement and members are held harmless.

Billing implicationHACs embedded in CMS Grouper affect DRG reimbursement; POA reporting and HAC identification may reduce payment but providers cannot bill members for the difference.

WSE expanded definition — wrong patient/body part/procedure; exclusions for emergent intraoperative changes

WSE elementsWrong patient, wrong body part, or wrong procedure inconsistent with correctly documented informed consent.

ExclusionsEmergent intraoperative situations where consent cannot be obtained and intraoperative discoveries or changes (e.g., pathology, adhesions, extra vertebrae) that justify altering the plan are excluded from WSE definition.

Related billing rulesFor WSEs, outpatient claim lines require modifiers PA (wrong body part), PB (wrong patient), or PC (wrong surgery); these will be denied as not covered and member held harmless. Inpatient claims must include specific diagnosis codes instead of these modifiers.

PSAE restated in document

Restated PSAEPSAEs are serious, identifiable, and unambiguous provider errors that are preventable and should never occur; policy follows NQF and includes CMS HACs.

Policy stanceThe Plan will not provide reimbursement or allow providers to retain reimbursement for care directly related to PSAEs; members are not liable for such care.

MonitoringThe Plan will monitor and incorporate state, federal, and advisory guidance (e.g., BCBSA, CMS) into procedures as appropriate.

WSE restated in document

Restated WSEA Wrong Surgical Event occurs when a practitioner performs the wrong procedure, on the wrong body part, or on the wrong patient; considered erroneous if inconsistent with documented informed consent.

ConsequencesAll operating room services when the error occurs and related services during the same hospitalization are not covered; providers in the OR who could bill are not eligible for payment, nor are providers in the same group or associated with the responsible provider for corrective services.

Claim handlingOutpatient/ASC/practitioner claims must append HCPCS modifiers PA/PB/PC (denied as not covered; member held harmless); inpatient submissions require specific diagnosis codes for the wrong surgical event.

PSAE (additional reference)

Additional PSAE referencePSAEs include but are not limited to certain surgical infections, surgery on wrong body part, surgery on wrong patient, and wrong surgical procedure; policy aligns with NQF list and incorporates BCBSA/FEP avoidable issues.

Member protectionMembers must be held harmless when HACs or PSAEs reduce payment; providers may not seek payment from members for the difference.

Subsequent servicesSubsequent services by providers not involved in the initial PSAE may be considered for reimbursement; providers responsible for the PSAE are not eligible for payment for corrective services.

WSE (additional reference)

Additional WSE referenceA procedure is 'wrong' if inconsistent with correctly documented and signed informed consent (wrong procedure, wrong body part, or wrong patient); includes wrong location within correct body part.

Outpatient handlingIf an outpatient PSAE/WSE is recognized prior to discharge, do not submit a claim or bill the member; if recognized after payment, notify Institutional Provider Relations to retract payment.

Inpatient handlingFor inpatient WSEs submit a no-payment UB-04 Type of Bill 110 for non-covered services and report the surgical error diagnosis code (e.g., MX/MY/MZ) on the no-pay claim; submit a separate inpatient claim for unrelated covered services if applicable.