Surgery is an operation or procedure that is performed for treatment of an injury, deformity, disease or condition, by manual or instrumental means.
There are many techniques utilized for surgery, such as cutting, abrading, suturing, and laser. However, not every operation or procedure has a successful outcome.
The Central Office on HCPCS has received several questions regarding whether an unsuccessful operation or procedure should be reported. In response to these questions, this article is being written to provide some direction in the coding and reporting of unsuccessful operations or procedures.
When a procedure is considered to have “failed,” specifically the expected result of the procedure is not achieved, the procedure is coded as performed.
Although, the procedure might be described as a failed procedure, in all actuality the procedure was performed and therefore should be coded.
Sometimes several unsuccessful attempts are made during the same operative episode to perform a procedure and finally the last attempt is successful.
In this instance, only one unit of a single code would be reported for the procedure successfully accomplished, regardless of the numerous attempts.
The unsuccessful attempts are considered a part of the successful procedure.
Discontinued procedures versus unsuccessful procedures
The term “unsuccessful procedures” is sometimes used interchangeably with “discontinued procedures.” Coders should understand that there is a difference between an unsuccessful procedure and a procedure that has been discontinued. An unsuccessful procedure would be a procedure that was performed but did not achieve the desired results.
A discontinued procedure means that the patient was taken to the treatment room for a planned procedure and/or the procedure was initiated, but for some specific reason the procedure was either cancelled or not completed.
Similar to the unsuccessful procedure, the specific discontinued procedure would be coded, but the difference is that a modifier (i.e., 52, 73, or 74) would be appended to the code to report that the procedure or service was reduced, discontinued, or cancelled at the physician’s discretion before or after the administration of anesthesia, if applicable. For additional information regarding discontinued procedures, see Coding Clinic for HCPCS, First Quarter 2007, pages 1-3.
To ensure that the unsuccessful or discontinued procedure is reported correctly, the coder must review the documentation thoroughly to identify whether the procedure was planned and/or started but cancelled/discontinued or the procedure was completed but the desired results were not achieved. If the documentation is unclear, the physician must be queried for clarification.
Let’s take a look at a few questions:
A single bone marrow biopsy from the hip was performed but no marrow was obtained.
How would this situation be coded? Would this be considered a reduced service?
Report CPT code 38221, Bone marrow biopsy, needle or trocar, for the bone marrow biopsy from the hip for the procedure performed. Whether the procedure was successful in obtaining expected results would not affect the code assignment.
When coding for reduced services the coder must take into consideration whether the procedure was changed (partially reduced or eliminated) from its original intent.
If documentation supports that the procedure was performed but the desired results were not obtained, the procedure would be coded. In this instance it would not be necessary to append a modifier.
In the outpatient surgical center of our hospital, a cervical epidural steroid injection was attempted 3 times but was unsuccessful.
The patient had been taken to the procedure room, prepared for the procedure, and given local anesthesia.
The needle was inserted several times but could not reach the C5- C6 space, and the procedure was finally aborted.
Would it be appropriate to report the CPT code for the cervical epidural steroid injection and append modifier 74?
Report CPT code 62310, Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography) of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic, with modifier 74, for the attempted but not completed cervical epidural steroid injection.
All attempts would be included in the reporting of one unit of the single CPT code.
A patient presented with multiple symptoms, and after examination the physician determined that a lumbar puncture (62270) is necessary.
After multiple attempts, the procedure was successful.
What are the appropriate code(s) for the lumbar puncture?
Report one unit of CPT code 62270, Spinal puncture, lumbar, diagnostic, for the successful lumbar puncture performed.
The lumbar puncture would only be reported once regardless of the multiple attempts that would be included in the code for the successful procedure.