Inpatient Facility Coding & Compliance Alert
Tie Canceled Surgery Back to Primary Diagnosis
Question: A patient was admitted for a total hip replacement (THR) because of severe arthritis in her hip. Prior to the surgery, the patient developed a fever. Her chest x-ray showed pneumonia. She was discharged and the surgery was rescheduled. What should we report as the principal diagnosis for the admission?
Answer: The primary diagnosis always reflects the reason the patient was admitted to the hospital. For a total hip replacement, submit 715.15 (Osteoarthrosis, localized, primary; pelvic region and thigh) as the primary diagnosis. Also include the appropriate pneumonia code as the secondary diagnosis. Finally, complete the claim with V64.1 (Surgical or other procedure not carried out because of contraindication) to document the reason for cancelling the surgery.
Plan ahead: For future discussions with this type of case, the hospital will need to present documentation regarding previous failed treatments which resulted in the need for the THR. This type of documentation will be especially necessary for pre-payment audits from RACs and MACs.
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Inpatient Facility Coding & Compliance Alert
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