06-29-2018, 09:41 AM | Community Wiki

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Cancelled surgery

  1. Default Cancelled surgery
    Medical Coding Books
    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?

  2. #2
    Default
    Hello Elizabeth,

    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.

    hope this helps.
    Marco Unzueta CIC, CPC
    - Medical Records Tech - Inpatient Coder
    - Outpatient Instructor
    AAPC El Paso Chapter - President

  3. Default
    yes this does help thank you for this information. Patient was not admitted was an out patient service.

  4. #4
    Default
    Happy to help!
    Marco Unzueta CIC, CPC
    - Medical Records Tech - Inpatient Coder
    - Outpatient Instructor
    AAPC El Paso Chapter - President

  5. #5
    Default
    What would be coded? Would it be the surgical CPT code with a 53 modifier?

    Peace
    ?_?

  6. #6
    Default
    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.
    Marco Unzueta CIC, CPC
    - Medical Records Tech - Inpatient Coder
    - Outpatient Instructor
    AAPC El Paso Chapter - President

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