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Billing related to postponed surgery

Compliance Monitor, June 16, 2006

Q:I have a question regarding proper billing procedures in the following scenario: The patient was brought in for a total knee replacement (inpatient only). Our preoperative area began to prep the patient, and during that time, the patient developed nausea and vomiting. Since the patient became ill, he was sent home without having the surgery.

The original intention was to admit the patient as an inpatient. Because the patient was sent home within about an hour of being registered and there were no room charges on the account, the status was changed to outpatient, and the procedure was billed with the CPT code for a total knee with a -73 modifier. The reason for the billing was to try to recoup the costs of the incidental services provided to the patient before he became ill.

The claim was denied because a total knee replacement is an inpatient-only procedure. However, when we spoke to our fiscal intermediary and explained the circumstances, we were told it was not billable as an inpatient either because there were no room and board charges.

Is there a procedure for billing an inpatient only procedure that is cancelled due to patient circumstances?

A:Yes. There are three applicable codes that can be used to recoup expenses in this circumstance

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