Aborted Procedure

• If the procedure was not even begun, don't code it at all -- 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.

I have to find a CCI code for a patient who was given cardiac anaesthesia for a scheduled aortic valve replacement, but upon TEE intraop, was found to not need the procedure. She was brought to ICCS for recovery, weaning & extubation AG REPLY -- as above, since the valve replacement was not done, don't code that. And we are NOT coding anesthesia alone. So the only thing that would be coded here is the echo. Tina identifies that we have an administrative CCI code for No procedure performed which is to ensure that CCI wasn't missed. What we probably need here is another administrative code to deal with the fact that there is a crosscheck NOT currently allowing somebody to come from OR without a CCI procedure code. This new admin code could be called something like "No codable procedure done in OR" with a made-up CCI picklist code.

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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.

Related Articles

Related articles:

CCI Collection ‎ (← links) Query check CCI from OR no CCI ‎ (← links) Task Team Meeting - Rolling Agenda and Minutes 2019 ‎ (← links) Failed Procedure (redirect page) ‎ (← links)