07/11/2024

What to Do if an Operative Case “isn’t completed”

Most procedures in your office go as planned, you assess, you determine what procedure is required and it is scheduled and performed, but there are cases when something happens.  Most procedures have a “global time frame” of either 10 days or 90 days, this includes the day before surgery, the surgery day and the time after.  Let’s review a few common scenarios for the professional coding of these cases:

Situation 1: The patient calls you the day before surgery and cancels because they have some other problem.  This case cannot be coded at all but the visit prior to surgery, if you had included it in your global service could be then coded at the appropriate E/M level based on medical necessity.  The ICD 10 code for the visit would be the ophthalmologic issue being managed.

Situation 2: The patient arrives at the ASC, office or facility and for whatever reason you determine the case cannot be performed.  This could be patient blood pressure, anxiety, acute infection or other issues.  The care would be coded with the E/M level of care based on the acuity of the case, the diagnoses for the ophthalmologic condition and the Z53.09 Procedure and treatment not carried out because of other contraindication.  If the case requires additional E/M assessment the  diagnoses code Z01.810 Encounter for other preprocedural examination would be added. An example of this would be a patient presenting for outpatient surgery and you did an assessment before sending the immediately to an ER or other medical provider.

Situation 3: The patient is in the chair and has been provided anesthesia for the procedure, at the appointment level, and positioned for the procedure, and perhaps the procedure has even begun and you stop because coughing, an asthma attack or some other acute issue.  In this case the care would  be coded with the CPT code for the procedure and the modifier 53 (example 66983-53). The diagnoses coding would include the diagnosis for the ophthalmologic condition, the T88.9xxA  Complication of surgical and medical care, unspecified, initial encounter and also code the cough (R05.8), Wheeze (R06.2), chest pain (R07.8) or whatever the issue is.

If a procedure has been performed but not the one scheduled due to the discontinuation, you can code that procedure code but also include the T88.9xxA and reason to identify why the original procedure was not performed, specifically if you have had to prior authorize the procedure or need to return to the OR to complete the procedure.

As always, make sure that your documentation reflects the issues you and the patient faced in the case and the information supports the diagnoses and modifier being coded.

Submitted by
Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant