CMS Modified NCD 328 for Wrong Body Part Surgery — What Billing Teams Need to Know in 2026
TL;DR: The Centers for Medicare & Medicaid Services modified NCD 328, its coverage policy for surgical or other invasive procedures performed on the wrong body part, effective January 9, 2026. Here's what changes for billing teams.
This update reaffirms — and in some ways sharpens — one of Medicare's oldest "never event" non-coverage rules. Wrong-body-part surgery billing is non-covered under CMS policy, full stop. No specific CPT or HCPCS codes are listed in this NCD, because the policy applies across the entire surgery section of CPT and any other invasive procedure. If your team bills for a procedure later identified as a wrong-site event, you're looking at a claim denial with no path to reimbursement under Medicare.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Surgical or Other Invasive Procedure Performed on the Wrong Body Part |
| Policy Code | NCD 328 |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Surgery, orthopedics, spine, cardiology, interventional radiology, dermatology, transplant, any specialty performing invasive procedures |
| Key Action | Audit your incident reporting workflow and confirm your compliance officer knows how wrong-site events trigger non-coverage under NCD 328 Medicare rules |
CMS Wrong Body Part Surgery Coverage Criteria and Medical Necessity Requirements 2026
NCD 328 is the National Coverage Determination governing CMS's position on surgical and invasive procedures performed on the wrong body part. The rule is not ambiguous: CMS does not cover these procedures. Period.
The medical necessity argument fails here by definition. A procedure performed on the wrong body part is not a reasonable and necessary treatment for the beneficiary's actual medical condition. That's the statutory standard under Medicare, and wrong-site surgery cannot meet it.
The CMS wrong body part surgery coverage policy traces back to the National Quality Forum's 2002 "Serious Reportable Events in Healthcare" report. That report identified 27 "never events" — adverse outcomes considered serious, largely preventable, and unacceptable to both patients and providers. Wrong-site surgery made the list. It still makes the list. The NQF now tracks 28 such events, and CMS has codified non-coverage for this one through NCD 328.
The policy covers a wide range of settings. Wrong-site procedures are non-covered across inpatient hospital, outpatient hospital, physician's services, skilled nursing facility, home health, rural health clinic, and federally qualified health center billing. There is no care setting under Medicare where a wrong-body-part procedure becomes billable.
Prior authorization does not apply here in the traditional sense — there is no authorization pathway that makes a wrong-site procedure reimbursable. The non-coverage is absolute. If your compliance officer is asking whether a prior auth might rescue a claim in this scenario, the answer is no.
CMS Wrong Body Part Surgery Exclusions and Non-Covered Indications
NCD 328 defines wrong-body-part procedures carefully. The definition matters for billing, because not every deviation from the surgical plan triggers non-coverage.
A procedure counts as "wrong body part" only when it is inconsistent with the correctly documented informed consent for that patient. This includes:
| # | Excluded Procedure |
|---|---|
| 1 | Surgery on the correct body part but the wrong side — left versus right for paired appendages or organs |
| 2 | Surgery at the wrong spinal level |
Three specific situations do not trigger non-coverage under this policy:
Emergent intraoperative situations. If an emergency arises during surgery and time pressure precludes obtaining informed consent, CMS does not classify the resulting procedure as erroneous. Document the emergent circumstances in detail.
Discovery of adjacent pathology. If the surgeon opens the patient and finds pathology close to the intended site, and the risk of a second surgery outweighs the benefit of pausing for patient consultation, proceeding is not considered a wrong-site event. Thorough operative notes are critical here.
Unusual physical configurations. Findings like adhesions, extra vertebrae, or other anatomical anomalies that alter the surgical plan at entry are excluded from the wrong-site definition.
These carve-outs are narrow. They are not a general escape hatch. If your billing team is reviewing a claim where the surgeon deviated from the consent and the situation doesn't clearly fit one of these three exceptions, loop in your compliance officer before submitting.
The breadth of procedures covered by this policy is also worth flagging for your billing guidelines training. CMS defines surgical and invasive procedures to include:
| # | Excluded Procedure |
|---|---|
| 1 | All procedures in the surgery section of CPT |
| 2 | Percutaneous transluminal angioplasty |
| 3 | Cardiac catheterization |
| 4 | Minimally invasive procedures using needles or trocars to enter a body cavity |
| 5 | Biopsies, excisions, and deep cryotherapy for malignant lesions |
| 6 | Multi-organ transplantation |
The policy excludes diagnostic instruments like otoscopes and minor procedures like drawing blood. But if it involves an incision, a natural body orifice, or instrument entry into a cavity — it's in scope.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Surgical or invasive procedure performed on the correct body part per documented informed consent | Covered (subject to other applicable coverage rules) | All applicable surgery-section CPT codes | Standard coverage rules apply |
| Surgical or invasive procedure performed on wrong body part (left vs. right, wrong spinal level, etc.) | Not Covered | All CPT surgery-section codes; all other invasive procedure codes | Non-coverage is absolute; no prior auth pathway exists |
| Intraoperative deviation due to emergent situation precluding informed consent | Covered (not classified as wrong-site) | Applicable CPT codes | Document emergent circumstances thoroughly in operative notes |
| Deviation due to discovery of adjacent pathology where second surgery risk outweighs consultation benefit | Covered (not classified as wrong-site) | Applicable CPT codes | Operative note must clearly document the pathology discovery and clinical reasoning |
| Deviation due to unusual anatomical configuration (e.g., adhesions, extra vertebrae) | Covered (not classified as wrong-site) | Applicable CPT codes | Document the anatomical finding explicitly |
CMS Wrong Body Part Surgery Billing Guidelines and Action Items 2026
The effective date of January 9, 2026 is already here. If your team hasn't reviewed your wrong-site event workflow in the context of this NCD update, do it now.
| # | Action Item |
|---|---|
| 1 | Train your billing team on what triggers non-coverage. Every coder and biller who touches surgical claims needs to understand that wrong-body-part events are non-covered under NCD 328, regardless of the CPT code on the claim. This is not a code-specific rule — it applies across all surgery and invasive procedure billing. |
| 2 | Review your charge capture process for flagging wrong-site incidents. Your charge capture workflow should have a hard stop when a wrong-site event is reported. A claim should not move forward on a procedure that your clinical team has identified as a wrong-site event. If that stop doesn't exist, build it in before your next billing cycle. |
| 3 | Confirm your operative note documentation standards address the three exceptions. Emergencies, adjacent pathology, and anatomical anomalies are all defensible — but only with documentation. Work with your medical director and OR nursing leadership to make sure operative notes capture this detail consistently. |
| 4 | Audit any denied claims where the denial reason involves wrong-site surgery. If you've received claim denials citing wrong-site errors in the past 12 months, pull those records. Confirm whether the exception criteria apply. If they do and you have the documentation, you may have grounds to appeal. If they don't, those denials are correct. |
| 5 | Do not submit claims expecting reimbursement for corrective procedures performed to fix a wrong-site error under the same encounter. The corrective care may be separately billable under different circumstances, but that's a separate analysis. Your compliance officer needs to be involved in any corrective procedure billing that arises from a never event. |
| 6 | Check your incident reporting integration. Many organizations have separate quality and billing workflows. A wrong-site event reported to your quality team should automatically flag the associated claim in your billing system. If those systems don't talk to each other, claims can slip through. Close that gap. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Wrong Body Part Surgery Under NCD 328
This policy does not list specific CPT, HCPCS, or ICD-10 codes. That's intentional — and it's the most operationally important thing to understand about wrong body part surgery billing.
NCD 328 applies across the entire surgery section of CPT and all other invasive procedures as defined by CMS. There is no finite code list to check against. The non-coverage determination applies based on the clinical circumstances of the procedure, not the specific code billed.
What This Means for Your Coding Team
You cannot look up a CPT code and determine from the code alone whether NCD 328 applies. The question is whether the procedure was performed on the wrong body part relative to the documented informed consent. That determination comes from the clinical record — the consent form, the operative note, the incident report — not from the code itself.
This makes cross-departmental communication non-negotiable. Your billing team cannot make this determination in isolation. When a wrong-site event is suspected or confirmed, your billing team, clinical documentation team, and compliance officer all need to be in the loop before the claim moves.
Supporting Code Guidance
Because no codes are enumerated in NCD 328, your Medicare Administrative Contractor (MAC) is your best resource for claims processing questions tied to specific procedures. MACs process wrong-site claims under the framework of this NCD, and their local guidance may supplement what CMS publishes nationally. Check your MAC's website for any local coverage determination (LCD) or article that references wrong-site events for your specialty.
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