Wiki O/P hospital coding for discontinued procedure

[smcmanus]

I am an o/p hospital coder. I use mody -74 on colonoscopy when discontinued and the use icd procedure code to actual extent of the failed colonoscopy along with the applicable v64.x code.. but I am wondering on a planned endometrial ablation w/d/c by hysteroscopy is discontinued due to the physician not being able to get a good seal..and thus only the d/c/hysteroscopy is done whether the -74 mody would be applicable here as well on the cpt with icd procedure coded to extent. All u hospital o/p coders..any suggestions?

 

[Anastasia]

58558 because that's what he did.

 

[mitchellde]

I am an o/p hospital coder. I use mody -74 on colonoscopy when discontinued and the use icd procedure code to actual extent of the failed colonoscopy along with the applicable v64.x code.. but I am wondering on a planned endometrial ablation w/d/c by hysteroscopy is discontinued due to the physician not being able to get a good seal..and thus only the d/c/hysteroscopy is done whether the -74 mody would be applicable here as well on the cpt with icd procedure coded to extent. All u hospital o/p coders..any suggestions?

If you code hospital outpatient then you do not use the Vol 3 procedure codes you use only the CPT codes, ICD-9 Vol 3 codes do not use modifiers. If the colonoscopy is discontinued then you code the code that was attempted and add the 74 modifier or you can code for the procedure to extend completed with no modifier.
for the second part if the hysteroscopy D&C was completed then that is the procedure you report with no modifier. You cannot code a discontinued procedure with a completed procedure. So when multiple procedure are planned but only some are performed you code only that which is performed. Again you use only the CPT code for hospital outpatient the Vol 3 ICD-9 codes are for inpatient use only.

 

[abctibbett@gmail.com]

"you cannot code discontinued procedure with completed procedure"

I have a question on this. What if the referral was for that particular procedure code, and it had to be discontinued. Then a lesser procedure was performed. Shouldn't I include the discontinued procedure for documentation's sake? Or just bill the completed procedure but drop to paper and send the OP notes as documentation?