Neurology & Pain Management Coding Alert

Question: Our physician decided not to take the patient for an elective surgical procedure. During the preoperative visit, the patient developed a fever and lung congestion. Our physician discussed this with the anesthesiologist and decided to cancel the procedure. How do we report this situation?

Montana Subscriber

Answer: Procedures might be aborted, postponed, or cancelled at any time when your physician perceives any potential 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 preop evaluation. Because the pre-anesthesia or preoperative form is usually comprehensive enough to satisfy the evaluation and management (E/M) requirements, you can bill the original exam with an applicable E/M code. Since this is a patient you already know, an established patient visit would be appropriate.

Submit the best-fitting E/M visit of 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient…) an office/outpatient visit or 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…. Usually, the problem[s] requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit)-99223 (… Typically, 70 minutes are spent at the bedside and on the patient’s hospital floor or unit) for an initial hospital visit.