2022 ASC Coding Tips: Discontinued Procedure Coding: Tips for Improving Accuracy

By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Director of Coding

Procedures may need to be terminated or discontinued for various reasons, including complications that may put the patient at risk. If the patient was in the operating or procedure room when the procedure was cancelled, the encounter can be coded and billed. Documentation is still required to support the encounter.

The following information must be documented by the surgeon:

• Preoperative diagnosis
• Planned procedure(s)
• If anesthesia was started
• Description of procedure(s) performed
• Reason for termination of the procedure(s)
• Any implants that were used during the procedure(s) (even if they were removed)

The above information will help the coder determine the appropriate coding for the encounter. According to CPT guidelines, if there is a CPT that fully captures the procedure performed, it should be coded instead of a discontinued procedure. For example, a surgeon begins an arthroscopic rotator cuff repair and the patient becomes severely hypotensive, causing the surgery to be stopped after the physician has only debrided the rotator cuff. The correct code would be for an arthroscopic debridement, not a discontinued rotator cuff repair.

If a procedure is cancelled in the procedure room before it’s started, the coder should code the planned procedure with the appropriate modifier to indicate the anesthesia status:

• Modifier 73 – Procedure discontinued prior to the administration of anesthesia
• Modifier 74 – Procedure discontinued after the administration of anesthesia

If multiple procedures are planned but none are performed, only the primary procedure is reported with the appropriate modifier. If one procedure is completed and a second is started but not completed, the coder should code the first procedure with no modifier and report the second procedure with modifier 74. Any additional planned procedures not started are not reported.

These guidelines do not apply to elective cancellations which are not reportable. The modifiers mentioned above are only for ASC and outpatient hospital use. Physician coding would be reported with the appropriate physician modifiers.

References

CMS Claims Manual; AHA Coding Clinic for HCPCS, Third Quarter 2011, Volume 11, Number 3, Page 7