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Cancelled Procedure Coding

  1. #1
    Scranton, PA
    Default Cancelled Procedure Coding
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    In an outpatient hospital setting we often times have cases were the patient's procedure must be cancelled for various reasons. Scenario 1: Patient comes to the outpatient surgery department at the hospital. The nurses take the patient's vital signs and determine the patient has a slight temperature (99.2). They contact the physician that is scheduled to do the procedure and he tells them to discharge the patient and have the contact his office to reschedule. Can this be coded as 99211 since the nurses did provide service as well as facility time was used? Scenario 2: Patient comes to the outpatient surgery department at the hospital. The nurse takes the patient's vital signs and let's the physician know that that some of the PAT tests (that were done the same morning) were elevated. The physician comes to the outpatient surgery department and discusses the test results with the patient and determines that the procedure should be rescheduled. Can this be coded as 99212? I am asking from the facility side and not the physician side.
    Any help and/or direction to supporting documentation would be greatly appreciated.

  2. #2
    Columbia, MO
    The outpatient facility levels are dependent upon the facilities criteria to determine the level. You do not use the same criteria as the physician (95/97 guidelines) The facility criteria may be unique to each facility and does not have to be the same as that which is used anywhere else. Also keep in mind it is not the physician activity you are capturing but think of it as facility resourses consumed during the encounter. So to answer you questions then the answer to both is yes, as long as your facility guidelines have been followed and that is the level met.

    Debra A. Mitchell, MSPH, CPC-H

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