CurrentMolina HealthcarePolicy N/A

Reimbursement policy for ICD-10-CM code category Y65 (misadventures during medical/surgical care)

Governs Molina Healthcare's reimbursement stance and billing guidance for claims involving ICD-10-CM Y65 codes, including which Y65-coded claims may be denied or recovered; applies to Molina providers submitting professional and facility claims.

Policy Summary

PayerMolina Healthcare

PolicyReimbursement policy for ICD-10-CM code category Y65 (misadventures during medical/surgical care)

Policy CodePolicy N/A

Change TypeClarified guidancecoding addition

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill facility claims with Y65.51–Y65.53 or professional claims with modifiers PA, PB, PC — such claims will not be paid and may be audited or recovered.

SourceLink

POLICY UPDATE CHANGES

The policy states Molina does not pay for facility claims with diagnosis codes Y65.51, Y65.52, or Y65.53 or professional claims with Modifiers PA, PB, or PC indicating a medical mistake.

The 2024 ICD-10-CM introduced Y65.8 as a specific code for other specified misadventures.

Y65.0–Y65.3, Y65.8Example ICD-10-CM codes discussed

Y65.51, Y65.52, Y65.53Facility diagnosis codes not paid

PA, PB, PCProfessional claim modifiers not paid

04/26/2024

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Payment Rules

Coverage and payment rules for Y65

Claims adjudication and payment rules for Y65‑coded events:

Molina does not pay facility claims with diagnosis codes Y65.51, Y65.52, or Y65.53.

Molina does not pay professional claims billed with modifiers PA, PB, or PC (indicating a medical mistake).

Molina reserves the right to reject, examine, audit, and recover claims based on medical necessity and proper coding practices; providers and facilities are expected to utilize industry standard coding practices for all submissions.

When improper billing and coding is not followed, Molina may deny the claim and recover claim payments; Molina reserves the right to revise this policy as industry practices change.

ICD-10-CM Coding Guidance for Y65

ICD-10-CM Y65 examplesICD-10

Y65.0	Mismatched blood in transfusion
Y65.1	Wrong fluid used in infusion
Y65.2	Failure in suture or ligature during surgical operation
Y65.3	Endotracheal tube wrongly placed during anesthetic procedure
Y65.8	Other specified misadventures during surgical and medical care (added 2024)

Coding specificity requirement — Y65

RequirementA 4th digit is required for all Y65 category codes (coding specificity must include the fourth character).

ScopeApplies to the ICD-10-CM Y65 category (misadventures during medical and surgical care).

Documentation guidanceEnsure the medical record supports the additional 4th-digit specificity when reporting Y65 codes.

Coding consequenceCodes reported without the required 4th digit may be considered noncompliant with coding standards and subject to claim adjustments or denials.

Claims Review, Denial & Recovery Authority

Denial Risk

Claims review, denial, and recovery authority for Y65-coded claims

Molina Healthcare reserves the right to reject, examine, audit and recover claims based on medical necessity and proper billing/coding practices. Facility claims submitted with diagnosis codes Y65.51, Y65.52, or Y65.53 will not be paid, and professional claims billed with modifiers PA, PB, or PC (indicating a medical mistake) will not be paid.

Molina may deny or recover payment when industry standard coding/billing practices are not followed.
Facility claims with Y65.51, Y65.52, Y65.53 are not payable.
Professional claims with modifiers PA, PB, PC are not payable.

Definitions

CMS — Definition

Agency nameCenters for Medicare & Medicaid Services (CMS).

Primary roleAdministers the Medicare program and partners with states to administer Medicaid and the Children's Health Insurance Program (CHIP).

Organizational placementA federal agency within the U.S. Department of Health and Human Services.

Relevance to policyCMS guidance and regulations are referenced for coding and reimbursement standards in this policy.