CurrentHighmark West VirginiaPolicy RP-036
Preventable Serious Adverse Events
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Defines the Plan's reimbursement rules for services related to preventable serious adverse events (including never events and hospital-acquired conditions) and describes billing requirements and member hold-harmless provisions for providers and facilities affected by such events.
Policy Summary
PayerHighmark West Virginia
PolicyPreventable Serious Adverse Events
Policy CodePolicy RP-036
Change TypeNo material change
Effective DateJul 27, 2026
Next Review Date
Key ActionAppend the applicable HCPCS modifier (PA, PB, or PC) to all outpatient/ASC/practitioner claim lines related to wrong surgical events and submit a no-payment Type of Bill 110 with inpatient-specific modifiers (MX/MY/MZ) for inpatient wrong surgical events.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
PA/PB/PCHCPCS modifiers required on outpatient claims
Type 110Inpatient no-pay claim
Held harmlessMember liability
Present on AdmissionPOA reporting
Appendix APSAE categories
2018–2024Update history
Reimbursement and Coverage Criteria for PSAEs
Reimbursement criteria for PSAEs, WSEs, and HACs
The Plan will not reimburse services related to PSAEs and requires specific billing actions; members are held harmless.
No reimbursement for any care directly related to a Preventable Serious Adverse Event (PSAE); the member shall not be liable for payment.
Providers may not knowingly seek payment from the Plan or the member for a PSAE or for services required to correct or treat problems created by a PSAE that occurred under the provider's control; subsequent services rendered by a provider not involved with the initial PSAE will be considered for reimbursement.
All providers in the same group, employed by, or associated with the provider(s) who caused or created the PSAE and who could bill or receive reimbursement for services to correct the error are not eligible for reimbursement.
For inpatient wrong surgical events, submit a no-payment claim (Type of Bill 110) for services related to the wrong surgical event; report the appropriate diagnosis code identifying the medical error. If other unrelated reimbursable services were provided during the same stay, submit a separate inpatient claim (Type of Bill 11X) for those services and report the same Statement Covers From and Through Dates on both claims.
On the inpatient no-payment (Type 110) claim report the appropriate inpatient surgical error modifier to identify the nature of the error: MX (wrong surgery on patient), MY (surgery on the wrong body part), or MZ (surgery on the wrong patient).
For outpatient/ASC/practitioner claims related to erroneous surgeries, append HCPCS modifiers PA, PB, or PC on each claim line related to the wrong surgical event; if an outpatient PSEA classified as a HAC is recognized before discharge, the facility should not submit a claim or bill the member.
All inpatient acute-care hospitals must populate Present on Admission (POA) data on all inpatient claims to identify HACs; if reimbursement is reduced due to a HAC, the provider may not bill the member for the difference and the member must be held harmless.
Providers discovering an outpatient PSEA after claim submission/payment should notify the Plan so reimbursement can be prevented or retracted; the member must be held harmless.
Subsequent services after HAC: Subsequent services to treat or correct problems created by NQF-listed HACs are not payable to the provider that caused the HAC; for CMS-recognized HACs not on the NQF list, CMS rules permit billing of reasonable and necessary services after discharge; the member must be held harmless except for normal cost-sharing.
Reimbursement and billing criteria for PSAEs
Coverage stance and operational rules for PSAEs (commercial market guidance present in these chunks):
The Plan will not provide reimbursement or allow providers to retain reimbursement for any care directly related to a PSAE; the member shall not be liable for payment.
All services provided in the operating room when an error occurs are considered related and therefore not covered; all providers in the operating room who could bill individually are not eligible for payment.
All related services provided during the same hospitalization in which the error occurred are not covered; all providers in the same group, employed by, or associated with the provider(s) who caused the PSAE are not eligible for payment.
Providers are required to append one of the following HCPCS modifiers on each outpatient/ASC/practitioner claim line related to a Wrong Surgical Event: PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient), or PC (Wrong Surgery on Patient). These lines will be denied as not covered and the member held harmless.
For inpatient wrong surgical events, providers must submit a no-payment Type of Bill 110 for the non-covered services and include the appropriate diagnosis code identifying the medical error; if unrelated covered services exist for the same stay submit a separate Type 11X claim for those services.
On the inpatient no-payment claim report the inpatient modifier that identifies the surgical error (MX, MY, or MZ) as specified for the Type 110 submission.
All inpatient acute-care hospitals must populate Present on Admission data on all inpatient claims to identify HACs; if payment is reduced due to a HAC the provider may not bill the member for the difference and the member must be held harmless.
When an outpatient PSEA that is also a HAC is recognized prior to discharge, the facility should not seek payment (do not submit a claim or bill the member). If recognized after submission/payment, notify Institutional Provider Relations to prevent or retract payment; the member must be held harmless.
Subsequent services: Providers are not permitted to seek payment for subsequent services required to treat or correct problems created by NQF-listed HACs; for other CMS-recognized HACs CMS rules on reasonable and necessary services apply. The member must be held harmless except for normal cost-sharing.
Non-covered indications and billing rules
Nationally non-covered indications and billing expectations for PSAEs:
Wrong procedure: A surgical or other invasive procedure is considered the 'wrong procedure' if it is not consistent with the correctly documented and signed informed consent for the patient; such procedures are non-covered.
Wrong body part: A surgical or other invasive procedure performed on the wrong body part (including wrong location on the correct side) is non-covered.
Wrong patient: A surgical or other invasive procedure performed on the wrong patient is non-covered.
Hospital outpatient, ASC, and practitioner claims: providers must append one of the following HCPCS modifiers to all lines when submitting a claim for the erroneous surgery(s): PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient), or PC (Wrong Surgery on Patient).
It is not an acceptable billing practice to refrain from submitting a claim because a PSAE or error occurred; claims must still be submitted.
Coding, Modifiers, and POA Reporting
Wrong surgical event modifiers and inpatient no-pay modifiersmixedNot Covered
| PA | Surgery Wrong Body Part |
| PB | Surgery Wrong Patient |
| PC | Wrong Surgery on Patient |
| MX | Wrong surgery on patient (inpatient no-pay) |
| MY | Surgery on the wrong body part (inpatient no-pay) |
| MZ | Surgery on the wrong patient (inpatient no-pay) |
Surgical error modifiersHCPCS | mixedNot Covered
| PA | Modifier - Surgery Wrong Body Part |
| PB | Modifier - Surgery Wrong Patient |
| PC | Modifier - Wrong Surgery on Patient |
| MX | Inpatient surgical error modifier - wrong surgery on patient (used on no-pay Type 110) |
| MY | Inpatient surgical error modifier - surgery on wrong body part (used on no-pay Type 110) |
| MZ | Inpatient surgical error modifier - surgery on wrong patient (used on no-pay Type 110) |
HCPCS modifiers for erroneous surgeriesHCPCSNot Covered
| PA | Surgery Wrong Body Part |
| PB | Surgery Wrong Patient |
| PC | Wrong Surgery on Patient |
Present on Admission reporting — All inpatient acute-care hospitals must populate POA data on all inpatient claims
RequirementAll inpatient acute-care hospitals must populate Present on Admission (POA) data on all inpatient claims
PurposeIdentify conditions not present at admission to implement HAC policy and adjust DRG or non-DRG reimbursement
ScopeIncludes critical access hospitals and children's inpatient facilities reimbursed as inpatient acute-care hospitals
Member impactIf payment is reduced due to a HAC not present on admission, provider may not seek the difference from the member (member held harmless)
Related actionPOA data is used in the CMS Grouper algorithm and separate Plan review processes for potential hospital-acquired conditions
Provider Billing Requirements and Actions
Billing Rule
Append HCPCS modifiers for wrong surgical events; use Type 110 no‑pay for inpatient errors
Append the applicable HCPCS modifier (PA, PB, or PC) on each outpatient/ASC/practitioner claim line related to a wrong surgical event. For inpatient wrong surgical events, submit a no‑payment Type of Bill 110 reporting the appropriate inpatient surgical error modifier (MX, MY, or MZ) on the no‑pay claim and include the diagnosis code identifying the nature of the medical error; submit a separate Type 11X inpatient claim for unrelated reimbursable services when applicable.
- Outpatient/ASC/practitioner claims: append PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient) or PC (Wrong Surgery on Patient) on each related claim line (these claim lines will be denied and the member held harmless).
- Inpatient stays with a WSE: submit a no‑payment claim (Type of Bill 110) for non‑covered services related to the WSE, include the appropriate inpatient modifier (MX = wrong surgery on patient, MY = wrong body part, MZ = wrong patient) on the no‑pay claim, report the diagnosis code identifying the medical error, and submit a separate Type 11X claim for covered services not related to the WSE with identical Statement Covers From/Through dates.
Prior Authorization
Required claim modifiers and inpatient reporting for PSAEs
Providers must append one of the HCPCS modifiers PA, PB, or PC on every outpatient/ASC/practitioner claim line for an erroneous surgery; inpatient submissions must include the specific diagnosis codes for the wrong surgical event and, when applicable, a no‑payment Type of Bill 110 with the inpatient surgical error modifier (MX/MY/MZ). Providers must also populate Present on Admission (POA) data on all inpatient claims and may not seek payment from the member for PSAE‑related services.
- Outpatient/ASC/practitioner: append PA, PB, or PC on each claim line related to the erroneous surgery (these lines will be denied as not reimbursable; member held harmless).
- Inpatient: report the specific diagnosis code(s) identifying the wrong surgical event; if a no‑pay claim is required, use Type of Bill 110 and report MX/MY/MZ on the no‑pay claim.
- Inpatient acute‑care hospitals: populate POA data on all inpatient claims to identify HACs.
- Do not seek payment from the member for PSAE‑related services.
Billing Rule
Must append PA/PB/PC on all claim lines; continue to submit claims despite PSAE
When submitting claims for erroneous surgeries, providers must append the applicable HCPCS modifier (PA, PB, or PC) to all claim lines; claims must still be submitted even when a PSAE or error occurred.
- Append PA (Surgery Wrong Body Part), PB (Surgery Wrong Patient) or PC (Wrong Surgery on Patient) to all applicable claim lines.
- It is not acceptable to refrain from submitting a claim because a PSAE or error occurred; submit claims per standard billing processes.
- For inpatient no‑pay scenarios, use the appropriate inpatient modifiers (MX/MY/MZ) on the Type 110 no‑pay claim and report the diagnosis identifying the error.
Definitions and Key Terms
Preventable Serious Adverse Event (PSAE)
DefinitionA serious, identifiable, and unambiguous occurrence or error made by a provider that is preventable and should never occur; includes NQF-listed serious reportable events and CMS-defined hospital-acquired conditions (HACs)
Scope examplesIncludes wrong surgical events and certain surgical infections (see Appendix A for full list)
Member liabilityMember shall not be liable for payment for any care resulting from PSAEs
Provider obligationProviders may not knowingly seek payment from the Plan or a member for a PSAE or services required to correct problems created by a PSAE
Billing expectationIt is not acceptable to refrain from submitting a claim because a PSAE or error occurred; claims must still be submitted
Wrong Surgical Event (WSE)
DefinitionA surgical or other invasive procedure erroneously performed as the wrong procedure, on the wrong body part, or on the wrong patient (inconsistent with correctly documented informed consent)
ConsequencesAll services provided in the operating room when an error occurs, and all related services during the same hospitalization, are considered related and not reimbursed; providers in the OR who could bill are not eligible for reimbursement
ModifiersProviders must append HCPCS modifiers PA (Wrong Body Part), PB (Wrong Patient), or PC (Wrong Surgery on Patient) on each claim line related to the WSE; these lines will be denied and the member held harmless
Group exclusionAll providers in the same group, employed by, or associated with the provider(s) who caused the WSE and who could bill for corrective services are not eligible for reimbursement
Detailed WSE exclusion notes
Core ruleWSE is a surgical or invasive procedure erroneously performed when inconsistent with the correctly documented informed consent (wrong procedure, wrong body part, or wrong patient)
Emergent intraoperative changesEmergent situations during surgery where informed consent cannot feasibly be obtained are excluded from WSE classification
Discovery-driven changesIntraoperative discovery-driven changes where the risk of a second surgery outweighs patient consultation (e.g., adhesions, unexpected anatomy) are not considered WSEs
Reimbursement implicationWhen a procedure qualifies as a WSE, related operating room services and related hospitalization services are not reimbursed
Surgical and invasive procedures
DefinitionOperative procedures that incise skin, mucous membranes, or connective tissue, or introduce an instrument through a natural body orifice; includes procedures in the CPT surgery section
Procedure rangeIncludes minimally invasive procedures through extensive multi-organ transplantation
Inclusion criteriaCovers all procedures described by codes in the CPT surgery section
Wrong procedure
Wrong procedureA surgical or invasive procedure not consistent with the correctly documented and signed informed consent for the patient
ImplicationSuch procedures are classified as non-covered indications under the policy
ReferenceDefined under the policy's Nationally Non‑Covered Indications
Wrong body part
Wrong body partA surgical or invasive procedure performed on the wrong body part (including wrong location on the correct side) inconsistent with the correctly documented and signed informed consent
ImplicationClassified as a non‑covered indication when inconsistent with consent
Relation to WSESpecifically enumerated as one of the three WSE types (wrong procedure, wrong body part, wrong patient)
Wrong patient
Wrong patientA surgical or invasive procedure performed on the wrong patient inconsistent with the correctly documented and signed informed consent
ImplicationClassified as a non‑covered indication under the policy
Relation to WSEOne of the three primary WSE classifications
Policy Summary
PayerHighmark West Virginia
PolicyPreventable Serious Adverse Events
Policy CodePolicy RP-036
Change TypeNo material change
Effective DateJul 27, 2026
Next Review Date
Key ActionAppend the applicable HCPCS modifier (PA, PB, or PC) to all outpatient/ASC/practitioner claim lines related to wrong surgical events and submit a no-payment Type of Bill 110 with inpatient-specific modifiers (MX/MY/MZ) for inpatient wrong surgical events.
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