The Centers for Medicare and Medicaid Services (CMS) wants to add three new categories of surgical mistakes to the list of “never events” it will not pay for:

  • Wrong procedures performed on a patient scheduled for surgery;
  • Scheduled procedures performed on the wrong patient; and
  • A procedure performed on the wrong body part.

The agency has been gathering comment on these proposed national coverage determinations. Final rules are expected to be announced in March and could affect payments to hospitals, physicians, and any other health-care providers or suppliers involved in an incident.

The three new categories would be added to the “preventable” errors and postoperative complications that the agency has refused to reimburse since October 1, 2008:

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  • Objects left inside a patient
  • Incompatible blood transfusions
  • Air embolisms
  • Deep venous thrombosis and pulmonary embolism
  • Surgical site infections
  • Urinary or vascular infections associated with catheterization
  • Mediastinitis after coronary artery bypass grafting
  • Inadequate glycemic control
  • Pressure ulcers
  • Injuries caused by falls in the hospital
  • Drug-induced delirium

“These errors result in increased costs to Medicare due to the need to treat the consequences,” explained Kerry Weems, acting CMS administrator.

While CMS controls only Medicare reimbursements, many large insurance companies across the country have adopted the first set of rules. That trend is not a response to an epidemic of egregious errors. Rather, it’s an attempt to encourage clinical vigilance and to contain ever-rising medical costs where possible.

“We’re not putting this in play because we’re seeing large numbers of complications,” said Susan Johnson, a spokeswoman for Blue Cross and Blue Shield of Kansas City, Miss. “But obviously, we are human and (adverse) medical events can happen.”

While it supports the goal of eliminating preventable errors, the AMA questioned the methodology in a letter to CMS from executive vice president and CEO Michael D. Maves, MD, MBA.

“It would make more sense to develop a clear payment policy outlining the circumstances under which surgery claims would not be payable,” Dr. Maves asserted. “CMS could, for example, instruct Medicare carriers to deny payment claims for these major surgical errors if a physician failed to use commonly accepted patient safety practices.”