Cancelled Surgery/No op report

[coderguy1939]

Patient was taken to OR given sedation and then surgery was cancelled due to contraindications. No op report was dictated by the surgeon. Is an op report necessary to code this surgery with a modifier 74? Thanks.

[joni57]

Do You Have A Hand Written One, So If The Insurance Company Would Ask For It?

Joni

[coderguy1939]

No, I don't have a hand-written report and the facility chart notes are minimal.

[trose45116]

was the surgery attempted at all or was it just canceled. i dont see how you could code the surgery if nothing was done but i still would have the doctor dictate what went on even though it was canceled.

[countrygalcpc]

You might get the anesthesia record and see if it verifies why the case was cancelled.

[coderguy1939]

If a patient is taken in to the O.R. and given anesthesia, in an ASC the originally planned surgery is coded with mod.74. and submitted to the patient's carrier for reimbursement. I'm trying to determine if the doctor is required to dictate a report that includes the reason for canceling the surgery or are facility chart notes acceptable if they include enough detail. .

[Anna Weaver]

I think, in order to code, the surgeon would have to dictate an OP report, even if it's just to say "no surgery due to: whatever reason indicated" then you should be able to code, because he should indicate that the patient was put to sleep and by whom, what the surgery was for in the first place, the patient went to recovery after waking up, etc.

[coderguy1939]

That's my take on it, too. I was hoping to find out if there are any guidelines indicating what the surgeon's responsibility is in a situation like this.

[RebeccaWoodward*]

http://www.medicarenhic.com/providers/pubs/ascguide.pdf

The reason for an ASC terminated surgery must be recorded in the medical record and must
indicate the following:
• Reason for termination of surgery;
• Services actually performed;
• Supplies actually provided;
• Services not performed that would have been performed if surgery had not been terminated;
• Supplies not provided that would have been provided if the surgery had not been
terminated;
• Time actually spent in each stage, e.g., pre-operative, operative, and post-operative;
• Time that would have been spent in each of these stages if the surgery had not been
terminated; and
• CPT-4 code for procedure had the surgery been performed.
Documentation must be provided upon request.
The appropriate modifier must be submitted to identify the services. See the Claim Billing Requirements.

[coderguy1939]

Thanks for all the input.