Starting October 1, 2009 Providers Must Report E-codes for Surgical Never Events

Effective October 1, 2009, the Centers for Medicare & Medicaid Services (CMS) will require all providers to submit E codes for three surgical “never events” despite not receiving payments for these procedures. More specifically, under the Inpatient Prospective Payment System (IPPS) final rule for fiscal year (FY) 2010 providers must report the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) E codes when filing claims for surgical “never events.”

  • E876.5 – performance of wrong operation (procedure) on correct patient;
  • E876.6 – performance of operation (procedure) on patient not schedule for surgery; and
  • E876.7 – performance of correct operation (procedure) on wrong side/body part.

CMS developed E codes E867.5 through E876.7 in response to the 2009 National Coverage Decisions published January 15, 2009. CMS anticipate that the reporting of E867.5 through E867.7 will contribute to CMS’ ongoing efforts to reduce payments for hospital acquired conditions as well as eliminate reimbursements for inadequate care.  CMS also announced that there will be modifications to the Medicare code editor (MCE). Under CMS’ current system, the MCE only triggers edits if an E code is reported in the principal diagnosis field. However, for discharges on or after October 1, 2009, MCE will trigger a “wrong procedure performed” edit and reject any claims reporting E876.5, E876.6, or E876.7 in the principal or secondary diagnosis fields.

According to the IPPS final rule for FY 2010, failure to report E codes for surgical “never events” could trigger Recovery Audit Contractor (RAC) audits and/or referral to the Department of Health and Human Services (HHS) Office of Inspector General (OIG). Thus, it is imperative for compliance officers, physicians, nurses, health information management departments, and billing personnel to be aware and understand how to appropriately bill E codes for surgical “never events.”

What are E Codes?
External causes of injury and poisoning codes, also referred to as E codes, were developed to provide data for injury research and evaluation of injury prevention strategies. E codes describe the cause and intent of an injury or poisoning. Moreover, E codes provide supplemental information to the ICD-9-CM diagnosis codes. For example, if a patient is admitted into the hospital for trauma (ICD-9-CM codes 800.0-999.9) further clarification regarding the trauma may be provided through the use of E codes (e.g. E813, motor vehicle traffic accident involving collision with another vehicle).