Cracking the Code

Discontinued Procedures for Inpatient Encounters

For inpatient coders, it is imperative that medical diagnoses are coded correctly and in proper sequence due to the importance of the correct diagnosis-related group (DRG) assignment. It is the coder’s responsibility to be sure all the reported procedures are fully supported by the documentation. Coders must verify whether a procedure was performed as planned because this directly impacts the DRG and reimbursement. When reviewing the provider’s operative report, coders should make note of key words throughout the documentation, such as aborted, attempted, abandoned, failed, incomplete, unsuccessful, etc. These key terms alert the coder that a procedure was canceled or discontinued. Per coding guidelines, coders are instructed to code the procedure to the root operation that was successfully performed. If the procedure was canceled before any other root operation was performed, then it is appropriate to code to the root operation Inspection of the body part or anatomical region inspected.

The thoracentesis was aborted, but the provider was able to successfully complete imaging.

Q: A provider orders a thoracentesis for a patient who was suspected of having pleural effusion. Chest ultrasound was performed to evaluate the pleural fluid. Per imaging report, the provider concludes that there is not enough fluid for drainage, so the thoracentesis was aborted.
A: BB4BZZZ, Ultrasonography of pleura
Reference: ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022 Section B3.3
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