04/30/2019 – Documentation for cancelled anesthesia

Question #1: If a case is cancelled after the pre-operative evaluation and before induction, what documentation should we include in this circumstance?

Answer:  After a pre-operative evaluation, a physician may decide to cancel a procedure prior to induction because of a patient’s health status or other circumstances such as equipment failure. In this case, the appropriate E/M code can be reported. In order for an accurate E/M code to be reported documentation must clearly state why the case was cancelled (e.g. case cancelled due to equipment failure).

The following documentation must be included when a case is                          cancelled before induction.

  • Reason for termination.
  • Services actually performed.
  • Time spent giving pre-op care.

 

Question #2: If a case is cancelled after induction, what documentation should we include on the record?

                        Answer:  Under certain circumstances, a physician may terminate a                                        surgical or diagnostic procedure due to extenuating circumstances or a                                     situation that threatens the well-being of the patient (risk to the patient if                              continued).

                   The following documentation must be included when a case is                                      cancelled after induction.

  • Reason for termination.
  • Services actually performed.
  • Time spent giving pre-op, operative and post-op care.
  • CPT code for the procedure, had it been completed.

The case will be billed with the total time the provider was present and the intended procedure that was to be done. Diagnosis code Z53.09 (procedure not carried out because of other contraindication) will be used in addition to the primary diagnosis code to alert the insurance carrier the case was cancelled.


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