If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
I had a question.. Pt was having surgery and had ekg, x-ray, labs, and day of surgery patient was uncooperative so surgery was cancelled how would you code this scenario and what would be your primary dx?
from what you are providing, if patient was admitted for a surgery (I'm assuming in this case scheduled) and the surgery was not performed due to the patient not cooperating, then you would code the diagnosis for what he was being admitted and going to have the surgery for and add an additional diagnosis of Z53.8 for "procedure and treatment not carried out for other reaons." as a secondary diagnosis.
at that point it depends on the third party payer.
For instance Medicare won't pay ASC surgeries that were canceled prior to starting the surgery (or providing anesthesia). Now this case is an outpatient surgery so you will be looking at modifier 73 if you were going to apply any. Since it will be based on the payer's policies it's hard to say if you would use the actual surgery code with that modifier, or if no bill will be created.
Best route will be to verify the insurance policies.