Wrong Surgical or Other Invasive Procedures Policy, Professional and Facility - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will not reimburse for a Surgical or Other Invasive Procedure, or for services related to a particular Surgical or Other Invasive Procedure when any of the following are erroneously performed.

  1. a different procedure altogether;
  2. the correct procedure but on the wrong body part; or
  3. the correct procedure but on the wrong patient.

Providers should report such services as described below, and are expected to waive all costs associated with the Wrong Surgical or Other Invasive Procedure Performed on a Patient. Participating providers may not bill or collect payment from UnitedHealthcare members for any amounts not paid due to the application of this reimbursement policy.

Policy Codes

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* COMM-Wrong-Surgical-or-Other-Invasive-Procedures-Policy.pdf
Click to Download: Wrong Surgical or Other Invasive Procedures Policy, Professional and Facility - Reimbursement Policy - UnitedHealthcare Commercial Plans

Q: How should a claim be submitted to UnitedHealthcare when a correct surgery and an erroneous surgery are performed together (ex: The surgeon was to remove the left hand thumb and fourth digit but instead removed the left hand thumb and fifth digit).

A: Hospitals would be required to submit two claims. The correct surgery and all related services would be submitted on one claim form and the erroneous surgery and all related services would be billed on a second claim form (Type of bill 110) with one of the listed ICD-10-CM codes to identify the type of erroneous surgery performed. Hospital Outpatient, ASC and Physicians must report one of the listed applicable HCPCS modifier(s) with the associated charges on all lines related to the surgical error, on a 1500 Health Insurance Claim Form. The charges associated with the correct procedure should not be reported with the modifiers PA, PB, or PC.