Coding, Classification & Reimbursement

1.  Cancelled Inpt Procedure and Root Op Inspection

Posted 05-26-2016 21:13

I am seeking guidance regarding how to code cancelled surgeries in ICD-10-PCS for inpatients. Wondering how to interpret ICD-10 PCS procedure guideline B3.3, Discontinued Procedures. If a patient who is scheduled for inpatient surgery is brought into the operating room and develops a contraindication to surgery prior to any induction of anesthesia, intubation, performance of a TEE, arterial catheterization, etc., would any procedure be coded at all?

Some coders feel that external inspection of the body part for which the procedure was to be performed should be assigned as a procedure code, based on guideline B3.3.

Some coders feel that if heart monitoring revealed an abnormality which caused the procedure to be cancelled prior to any incision, induction, etc., perhaps code 4A12XCZ, Monitor Cardiac Rate, external, would be applied?

Other coders feel that in this situation NO PROCEDURE CODE would be applicable.  

The guideline states:

If the intended procedure is discontinued, 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.

  • If no root operation is performed, some coders are interpreting this to mean that an inspection procedure would be assigned.
  • Other coders are interpreting this to mean that root operation inspection is assigned only if there is some type of root operation performed by the surgeon, such as an incision, insertion of a scope, puncture, etc., the objective of which was to accomplish a surgery/procedure which could not be completed. To represent an incision, the only choice in ICD-10-PCS is inspection since the coding classification does not contain codes for incision or puncture, etc., without another objective.

Discontinued procedures

B3.3

If the intended procedure is discontinued, 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.

Is anyone else wrestling with this question or have any advice as to how to handle this guideline?  Thanks so much for your help.

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Josephine Scott RHIT
IP Coding Trainer/Auditor
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2.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 05-26-2016 21:57
Edited by Carlo Quinto 05-26-2016 22:02

In my understanding about the guidelines mentioned if there is NO ANY other root procedure done you may use the Root Operation Inspection of the body part Inspected. but if cardiac monitoring was done which determined the cancellation of the procedure then it should be coded. if no other diagnostic procedure done or atleast no Inspection of body part or anatomical region then there is no code to be assign for the procedure and just use the ICD-10 diagnosis for canceled procedure to capture the scenario.

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Carlo Quinto
Certified Medical Coder



3.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 05-27-2016 07:39
  |   view attached

Interesting discussions.  I am going to assume that you are coding in ICD-10-PCS because you work for a hospital and you are coding an inpatient encounter and you will externally report this.  If that it is the case you need to adhere to the Uniform Hospital Discharge Data Set (UHDDS).  The UHDDS instructs that all significant procedures are to be reported and it defines significant procedure to be one that is

  1. surgical in nature, or
  2. carries a procedural risk, or
  3. carries an anesthetic risk, or
  4. requires specialized training

This does not prevent you from coding minor procedures, but you should determine if there is any reason to assign codes for such procedures.  Some hospitals might need to report procedures that do not meet UHDDS definition of significant procedure for internal reporting purposes, state data reporting requirements, or third party payer requirements.  For any procedures that your facility requires to be reported above and beyond that which is required by UHDDS you should describe in your facility-specific guidelines.

With all this in mind I don't see why you would report a procedure code on an inpatient encounter if no procedure was performed.  Certainly no significant procedure was performed if the procedure was cancelled before it was even started.  I am speaking strictly in terms of inpatient reporting by hospitals using ICD-10-PCS codes.  The reporting of procedures in CPT/HCPCS is an entirely different topic.

I was doing some research a while back where I felt it was necessary to actually look at the July 31, 1985 Federal Register where the 1984 revisions of UHDDS were published.  I located a microfilm/microfiche copy and copied and pasted it into a Word document.  I have attached it if you are interested.  These are also included in the Coding Clinic for ICD-9-CM July-August 1985, pp. 4-8.

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Judy Bielby
Clinical Assistant Professor

Attachment(s)



4.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 06-02-2016 18:12

Cancelled procedures where no procedure whatsoever occurs would not be coded as a PCS px in a hospital inpatient setting. The diagnosis code Z53.09 Procedure and treatment not carried out because of other contraindication would be assigned per your description.

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Laura C. Jones, RHIT, CCS
AHIMA Approved ICD-10-CM/PCS Trainer
Coding Auditor



5.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 08-10-2016 14:50

What if the patient had a intraoperative cholangiogram that was attempted but then not carried out but the surgeon did do a cholecystectomy.

Do you just code the cholecystectomy or do you also need the inspection code?

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Cheryl Ervin
Director, Health Information Services
Community Hosp of Bremen



6.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 21 days ago
​Was there a response to this one? Would it be appropriate to code inspection of hepatobiliary duct along with the cholecystectomy? When the cholangiogram is aborted and only a cholecystectomy is performed.

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Cynthia Navarro
Inpatient Coding Auditor
JPS Health Network
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7.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 21 days ago
​​I would state NO as Inspection is not located in the Section Value B - Imaging - Intraoperative cholangiogram would be with Section B.  There is a list of Medical and Surgical Section Root Operations and Obstetric Root Operations in Appendix B for your review.

Root operations for Imaging include MRI, Ultrasonagraphy, etc.

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Debra Martin
Regional Interim Coding Manager
Kaiser Permanente
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8.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 10 days ago
In that scenario only code for the cholecystectomy, the "attempted" intra-op cholangiogram procedure is not coded separately and should not be coded to inspection.

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Carlo Quinto
Certified Coding Specialist,
Registered Nurse.
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9.  RE: Cancelled Inpt Procedure and Root Op Inspection

Posted 7 days ago
​I have an inpatient surgical case I am having an issue assigning the PCS code as well. Patient went to the OR room for hip replacement, anesthesia was administered, foley cath was inserted by the nursing staff. Patient had pyuria so the procedure was cancelled. Patient was under anesthesia for about 15 minutes. There are OR, anesthesia and recovery room charges on the claim that require a PCS code to be assigned. I'm thinking of using administration of anesthesia. Any thoughts?

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Tammie Stephenson
Associate Director of Coding/CDI
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