Health Information Management

Unsuccessful v. aborted/discontinued procedures

HIM-HIPAA Insider, February 17, 2004

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You and your coders should understand that the definitions of unsuccessful and aborted/discontinued procedures are quite different. When a procedure is considered to have "failed," in that it was not successful in achieving the intended result or every objective of the procedure could not be carried out, the procedure is coded as performed (per the ICD-9-CM Coding Handbook).

For example, occasionally there is an almost immediate reocclusion of the coronary artery after a patient undergoes a percutaneous coronary angioplasty (PTCA). The reocclusion necessitates a return to the operating room so the doctor can perform a coronary artery bypass (CABG) to correct the problem.

The angioplasty may be described as a failed procedure, but, in fact, a procedure was performed and you should code it. Don't classify failure to achieve the therapeutic objective as a complication of the procedure. If during the procedure, and before the completion of the PTCA, it became obvious that the doctor must perform a coronary artery bypass procedure, you would only code the CABG.

Make sure your coders don't confuse unsuccessful results after completed surgical procedures with aborted/discontinued procedures. A completed procedure is still considered a completed procedure, whether or not it results in the appropriate or expected therapeutic results. If this is the case, you shouldn't report the procedure with a -52, -73, or -74 modifier.



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