# Termination of surgery



## Cookie2! (May 2, 2008)

Help Please; Can anyone tell me how I would code This:
Pt was sceduled to have surgery (62264, 72275, 77003) but after prepping and before procedure started pt terminated the procedure prematurely secondary to anxiety unable to lie still on table, stated they felt choking sensation. How would I code this?


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## haadi (May 13, 2008)

Hello,

take modifier 73 since the anaesthesia not given prior to discontineu the procedure also take 72275 only since 77003 is inclusive to the 72275  

thank you!


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## haadi (May 13, 2008)

72275 is only used if there is an epidurogram performed, images documented, and above all a formal radiologic report is issued.

so the final codes would be like:

62264  73  1)dx 2)v64.2

72275 ( if the above criteria meets) tc/26

hope this helps.


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## amitjoshi4 (May 13, 2008)

*Termination Procedure*

Hello Cookie2

Where the procedure was cancelled is an important issue.

Outpatient facilities may also face the task of reporting one or more discontinued or cancelled procedures when multiple procedures are planned. 
a. When one or more planned procedures are completed, report the completed procedures. Any other procedure(s) that were planned, and not started, are not reported.
b. When none of the planned procedures are started and no anesthesia is administered, the first planned procedure is reported with modifier 73. In this instance, the patient must have been prepared and taken to the procedure room.
c. If anesthesia has been administered or the first procedure has been started (e.g., scope inserted, intubation started, incision made, etc.) modifier 74 should be reported with the first procedure. The other procedures are not reported.
d. If the first procedure is terminated prior to the administration of anesthesia and before the patient is taken into the procedure room, the procedure should not be reported.
e. If the first procedure is completed and a second procedure is started but not completed, the second procedure is reported with modifier 74 and the first procedure is reported with no modifier.
Keep in mind that in order to report modifiers 73 or 74, the patient has to be taken to the room where the procedure is to be performed.

*Discontinued Procedures vs. Unsuccessful Procedures *

Surgery is an operation or procedure that is performed for treatment of an injury, deformity, disease or condition, by manual or instrumental means. 
There are many techniques utilized for surgery, such as cutting, abrading, suturing, and laser. However, not every operation or procedure has a successful outcome. 
The Central Office on HCPCS has received several questions regarding whether an unsuccessful operation or procedure should be reported. In response to these questions, this article is being written to provide some direction in the coding and reporting of unsuccessful operations or procedures.
When a procedure is considered to have "failed," specifically the expected result of the procedure is not achieved, the procedure is coded as performed. 
Although, the procedure might be described as a failed procedure, in all actuality the procedure was performed and therefore should be coded.
Sometimes several unsuccessful attempts are made during the same operative episode to perform a procedure and finally the last attempt is successful. 
In this instance, only one unit 
of a single code would be reported for the procedure successfully accomplished, regardless of the numerous attempts. 
The unsuccessful attempts are considered a part of the successful procedure.

*Discontinued procedures vs. unsuccessful procedures*
The term "unsuccessful procedures" is sometimes used interchangeably with "discontinued procedures." Coders should understand that there is a difference between an unsuccessful procedure and a procedure that has been discontinued. An unsuccessful procedure would be a procedure that was performed but did not achieve the desired results. 
A discontinued procedure means that the patient was taken to the treatment room for a planned procedure and/or the procedure was initiated, but for some specific reason the procedure was either cancelled or not completed. 
Similar to the unsuccessful procedure, the specific discontinued procedure would be coded, but the difference is that a modifier (i.e., 52, 73, or 74) would be appended to the code to report that the procedure or service was reduced, discontinued, or cancelled at the physician's discretion before or after the administration of anesthesia, if applicable. For additional information regarding discontinued procedures, see Coding Clinic for HCPCS, First Quarter 2007, pages 1-3.
To ensure that the unsuccessful or discontinued procedure is reported correctly, the coder must review the documentation thoroughly to identify whether the procedure was planned and/or started but cancelled/
discontinued or the procedure was completed but the desired results were not achieved. If the documentation is unclear, the physician must be queried for clarification

Hope this will solve the query. Any further help do not hesitate.

Thank You.


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## jacubillas (Feb 12, 2010)

*Cancelled procedures*

Regardless of why a procedure is cancelled, can't a facility still bill out supplies and meds that were used up to the cancellation?


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