Ensure compliance and proper reimbursement using this guide to coding discontinued inpatient procedures.
In the inpatient coding world, a great deal of importance is placed on coding to derive the correct diagnosis-related group (DRG) assignment. As coders, part of our responsibility is to review medical record documentation. We must verify whether a procedure was performed as planned and code accordingly, as this ultimately impacts Medicare severity diagnosis-related groups (MS-DRGs) and reimbursement.
Identify Discontinued Procedures
Inpatient coders must be able to recognize whether a procedure was performed in its entirety to be able to code it properly. A discontinued procedure is one that is canceled or not fully accomplished under the procedure definition. To determine if a procedure was discontinued, look for the following key terms in the documentation:
In the ICD-10-PCS Official Guidelines for Coding and Reporting, there is only one guideline for discontinued procedures:
B3.3 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.”
Coding guidance: Any time you are looking up procedures in ICD-10-PCS, start by asking yourself the following questions:
- What was the planned procedure?
- Was the planned procedure performed?
- If not, why was the planned procedure not performed?
- What was the actual procedure performed?
- What is the:
- Body system?
- Root operation/index main term?
- Body part/index sub-term?
- What is the appropriate ICD-10-PCS code for this procedure?
Let’s review a couple examples of how to apply this guideline to clinical scenarios.
Case Study 1
Procedure note: A 37-week-old baby weighing 2,120 grams. Prenatal diagnosis of two life-threatening congenital anomalies associated with a chromosomal deletion. The infant was born via spontaneous vaginal delivery and intubated immediately and placed on mechanical ventilation. The infant’s condition deteriorated to the point that the only therapeutic option left was extracorporeal membrane oxygenation (ECMO) because of the degree of hypoxic respiratory failure.
General anesthesia was given, and an incision was made on the right side of the neck. Arteriotomy was performed, followed by dilation using the Seldinger technique with cook vascular dilators over a wire. An arterial cannula was placed into the right common carotid artery; no device was placed. Venotomy was performed on the right jugular vein and an attempt was made to pass the cannula; unable to get the vessel to the appropriate size to accommodate the jugular catheter. Had to stop the venous cannulation at this point. Cannulation for dilation of right common carotid artery was performed without placing any device. Unsuccessful attempt at ECMO. Baby expired.
Case analysis: For case study 1, the planned procedure was ECMO, but ECMO was ultimately not performed. Per the documentation, cannulation for ECMO was attempted but could not be done due to inadequate vessel size. The surgeon was unable to get the vein to the appropriate size to accommodate the jugular catheter, so cannulation was stopped. The actual procedure performed was dilation of the common carotid artery. The term “cannulation” in the ICD-10-PCS code book directs you to see other terms like bypass, dilation, drainage, irrigation. Select the term “dilation” as this was the objective of the procedure. The root operation for this procedure is Dilation. The table below describes the answers to the remaining questions for case study 1:
|Section(0)||Body System(3)||Operation(7)||Body Part(H)||Approach(0)||Device(Z)||Qualifier(Z)|
|Medical and Surgical||Upper Arteries||Dilation||Common Carotid Artery. Right||Open||No Device||No Qualifier|
Do not report the code for ECMO as the intended procedure was not completed. In this case, you should only code the root operation that was performed. The correct ICD-10-PCS code for this procedure is 037H0ZZ Dilation of common carotid artery, open approach.
Case Study 2
Procedure note: A 54-year-old male was admitted due to shortness of breath associated with a cough and low oxygen saturation. Patient was found to have left lower lobe consolidation indicative of pleural effusion. A thoracentesis was ordered. Plan: thoracentesis by the interventional radiologist. Hold Eliquis.
Chest ultrasound was performed to evaluate the pleural fluid. Imaging showed there was only a trace amount of fluid; not enough to be able to drain safely. The radiology report indicated there was trace amounts of pleural fluid on the left, but not enough to drain safely. Impression: Due to the low fluid level found on imaging prior to attempting thoracentesis, the complete procedure was not performed.
Case analysis: For case study 2, the planned procedure was thoracentesis, but a thoracentesis was ultimately not performed. Per the documentation, ultrasonography showed that there was only a trace amount of fluid in the left pleural space, not enough to be able to drain the fluid safely. The actual procedure performed was an ultrasound of the chest to evaluate the pleural fluid. Ultrasonography (real-time display of images of anatomy or flow information developed from the capture of reflected and attenuated high-frequency sound waves) is the root operation. The table below describes the answers to the remaining questions for case study 2:
|Section(B)||Body System(B)||Type(4)||Body Part(B)||Contrast(Z)||Qualifier(Z)||Qualifier(Z)|
Do not report the code for thoracentesis, as the intended procedure was not completed. In this case, you should only code the root operation that was performed. The correct ICD-10-PCS code for this procedure is BB4BZZZ Ultrasonography of pleura.
- When you review the medical record documentation, read the operative report fully. Make sure you understand the documentation and look to see if it indicates whether the planned procedure was performed.
- If the planned procedure was not performed or was discontinued, code the procedure to the root operation performed.
- If appropriate, report the ICD-10-CM codes for the procedures and treatments not carried out.
Best practices for assigning ICD-10-PCS codes:
1. Pick a root operation that identifies the main objective of the procedure.
2. Locate the correct table.
3. Pick the remaining characters for the body part, approach, device, and qualifier.
Don’t Forget the Dx
When appropriate, report the applicable ICD-10-CM diagnosis codes for any procedures or treatments not carried out. Depending on the circumstances, this allows for the ability to capture the nature of the discontinued procedure. Keep in mind this is not always appropriate in the inpatient setting.
Now you should be ready to assign the appropriate ICD-10-PCS and ICD-10-CM codes for discontinued procedures to ensure coding compliance and avoid inpatient coding denials.