Neurosurgery Coding Alert

Question: Our surgeon decided not to take the patient for an elective surgical procedure. The patient who was in pre-operative visit, was found to have developed a fever and lung congestion. Our surgeon discussed this with the anesthesiologist and decided to cancel the procedure. How do we report this situation?

Oklahoma Subscriber

Answer: Procedures might be aborted, postponed, or cancelled at any time when your surgeon 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 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.  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.

Note: 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.”