Aborted Procedure

If the procedure was not even begun, code No codable procedure done in OR -- e.g. taken to, perhaps was put to sleep, but the surgeon/proceduralist never began doing the planned procedure.
If on the other hand, a procedure WAS begun but the surgeon or proceduralist, for whatever reason, didn't do what was planned, then code WHATEVER WAS ACTUALLY DONE.
- e.g. planned a colon resection for colon cancer, opened the patient, saw that there was diffuse peritoneal carcinomatosis, and then just closed, then code the diagnostic exploratory lap, i.e. (D) Abdominal, Pelvic or Peritoneal Cavity, NOS + Inspection, Exploration (non-endoscopic)
  - if they did a biopsy also before they closed, then code as above AND ALSO the biopsy as: (D) Abdominal, Pelvic or Peritoneal Cavity, NOS + Biopsy (non-endoscopic)
- e.g. they started a thrombectomy on the carotid artery of a stroke patient, but were unable to finish it, then here you'd code the thrombectomy because they went in and made the attempt.

Background
We decided that our coding will not track whether a procedure was aborted (aka a "failed procedure"), or was a failed procedure while still in surgery, as part of CCI Collection. We used to specifically collect failure or abandonment status on some procedures (e.g. inoperable cancer). In CCI, failure would need to be coded by appending "Status A" after the code. This would require an extra field for something we never generally coded before, so it was decided not to code this. Later, we realized that not coding a procedure code in this scenario would make it impossible to have check query check_CCI_from_OR_no_CCI, so we added an administrative code to deal with this.

Related Articles