2/27/14 – 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 apre-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.

 

1) Reason for termination.

2) Services actually performed.

3) 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.

 

1) Reason for termination.

2) Services actually performed.

3) Time spent giving pre-op, operative and post-op care.

4) CPT code for the procedure, had it been completed.

 

Also, attach a brief note and point out the percentage of the procedure that was finished and why the procedure had to be stopped. Example:

 

“50% of the procedure was completed. It was stopped because the patient                          went into cardiac arrest.”

 

We will submit the ASA code for the portion that was performed along with a modifier 53 which alerts the insurance the case was discontinued.

 


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