Inpatient Facility Coding & Compliance Alert

Question: The anesthesiologist completed the standard preoperative visit but believed the patient was not a good elective surgical candidate because she had a fever and lung congestion. He discussed the situation with the surgeon, and the surgeon canceled the case. How do we report this situation?

Oklahoma Subscriber

Answer: Procedures might be aborted, postponed, or cancelled at any time when the anesthesiologist or surgeon sees some risk that could threaten the patient’s health if the case continues.

If the rescheduled date is several weeks in the future (usually two or more), then it will merit another complete pre-op evaluation. Because the pre-anesthesia or preoperative form is usually comprehensive enough to satisfy the E/M requirements, you can bill the original exam with an applicable E/M code. If the payer accepts consultation codes, look at 99241- 99245 for office/outpatient or 99251-99255 for inpatient. Otherwise, submit the best-fitting E/M visit of 99201-99215 an office/outpatient visit or 99221-99223 for an initial hospital visit.

Note: The anesthesiologist’s second pre-op visit (when the case actually takes place) is included in the base value of the anesthesia service at the time of surgery. In the past, you might have reported the cancelled visit with an E/M code and modifier 53 (Discontinued procedure) but that’s no longer correct. Current CPT® guidelines state that you don’t use modifier 53 “to report the elective cancellation of a procedure prior to a patient’s anesthesia induction and/or surgical preparation in the operating suite.”