Cancelled procedure after anesthesia

Jim Pawloski

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How would you code this scenario?

Patient brought in the cath lab for a heart catheterization, ordered as a left heart cath. Patient is placed in the exam table and prepped and draped. 10 cc of lidocaine injected over the right femoral artery. Moderate sedation was given. Patient develops shortness of breath and cannot lay flat. Procedure cancelled.

Thanks,
Jim Pawloski, CIRCC
 

thomas7331

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The facility can bill the code for the planned procedure with a modifier 74. The physician can only bill for what was actually done, so if the procedure was not actually started, then no professional fee can be billed.
 

Jim Pawloski

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I am billing for the facility. There was not a OP note, all my information was from the procedure notes of the cath lab.
Thanks for your responses, does anyone else have an opinion?

Jim
 

ernist8489

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Jim I feel like the only way to go is with a 74 As after moderate conscious sedation was administered he got shortness of breath, so procedure cancelled after anesthesia was admin.
 
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