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.