Cracking the Code
Discontinued Procedures for PCS Codes
A discontinued procedure is one that is canceled or not fully accomplished under the procedure definition. Per ICD-10-PCS Coding Guidelines Section B3.3, it is appropriate to code the procedure to the root operation performed if the intended procedure is discontinued. If a procedure is discontinued before any other root operation is performed, then the code root operation Inspection of the body part or anatomical region inspected. It is the coder’s responsibility to recognize whether a procedure was performed in its entirety in order to properly code it.
When reviewing the provider’s documentation, it is important to look for key words that highlight a discontinued procedure (such as aborted, attempted, abandoned, failed, incomplete, or unsuccessful). Here are a couple of helpful coding tips when reviewing medical record documentation:
- Read the operative report fully to see if the planned procedure was performed.
- If the planned procedure was not performed, then be sure to code the procedure to the root operation performed. Be sure that the root operation identifies the main objective of the procedure.