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.
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.
3) Time spent giving pre-op, operative and post-op care.
4) CPT code for the procedure, had it been completed.
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.