How are others interpreting this PCS Guideline B3.3 ? If a procedure is cancelled due to A Fib, say a resection of the lung, but the cancellation is after IV ringer's lactate and one dose of fentanyl given (anesthesia start) – would an inspection of the lung be appropriate? The example provided seems to infer some portion of the total procedure must be initiated in order to use inspection.
Discontinued or incomplete procedures
If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.
Example: A planned aortic valve replacement procedure is discontinued after the initial thoracotomy and before any incision is made in the heart muscle, when the patient becomes hemodynamically unstable. This procedure is coded as an open Inspection of the mediastinum.
Cindy Greathouse, MHA, RHIA, CCS
Manager, Inpatient Clinical Coding
Maine Health | Maine Medical Center
Revenue Cycle – CBO Coding
Office: 207-396-6815 Cell: 207-713-4459