discontinued procedure help!!

cmcruz

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I have a cardiothoracic surgeon who planned on performing an aortic valve replacement. The patient was administered anesthesia, prepped and taken to OR, he performed a median sternotomy and removed the heart. When he visualized the aortic valve he felt it may be risky to continue, an intraoperative TEE was done and he consulted the patient's cardiologist at which point he decided it was too risky to continue with the procedure (AVR) for the patient's well being and he terminated the procedure. He never clamped the valve and he did not start bypass. Would you code the AVR with a modifer 53? Or would you code the median sternotomy and aortic valve exploration? I appreciate any help!
 
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CT surgery NOT my forte

CT Surgery is NOT my area of expertise ... however ...
If the surgeon completed a definitive procedure I would code for that.

You will likely get a more accurate / qualified response if you post your question in the CT Surgery thread - with the scrubbed operative note. The more complicated the case, the more we need to see the note before giving you a response.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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