Process for In-Patient and Out-Patient Cancelled Procedures by DWt7kRZs

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									                                   POLICY/ PROCEDURE/PROTOCOL
Title: Process for In-Patient and Out-Patient Cancelled Procedures            Policy # MR.20
Audience: Corporate


Key Word:    Cancelled, no show                                               Date            Page:
                                                                              Issued:
                                                                              5/3/10           1 of 6
Distribution: All holders of the policy and procedure manual


Prepared by:                                                                  Effective
Director, Health Information                                                  Date: 5/17/10
Manager Health Info Coding Education
Manager Revenue Audit Process
Director, Patient Management

Approved by:                                                   Date:
Vice President, Revenue Cycle Operations                       3/10
Nursing Executive Committee                                    3/10
OR Committee                                                   3/10
Corporate Policy Approval Committee                            4/10

Regulation/ Standards-
NYS: N/A
Federal: Medicare Transmittal 442, 1/21/05
Joint Commission: N/A
CMS.40.4 Rev. 1514 Medicare Claims Processing
Review Date
Revision Date



I.     Introduction
       This policy & procedure is to assist Kaleida staff in the appropriate registration, documentation,
       charging and assignment of ICD-9-CM & CPT-4 codes to paper and electronic medical records
       where the surgical procedure was cancelled. This policy is also intended to assist Procedure
       Areas (including interventional radiology) in documenting cancelled procedures and Health
       Information staff in obtaining the original paper medical records and the specific documentation
       for the attempted procedure performed to support coding and billing. In addition, this policy is
       intended to assist Kaleida Staff in the appropriate classification of cancelled procedures and the
       determination of when a case is a Leave of Absence (LOA).


II.    Communication and Responsibility
       Registration Managers, Patient Management Services Case Workers, Nurse Managers, Patient
       Financial Services Managers, and Health Information Site Supervisors and Managers will
       administer this policy.


III.   Scope of Practice
       This policy and procedure applies to Registration, Ambulatory Surgery Units/All Outpatient
       Procedure Areas, Health Information, Patient Management Services, and Patient Financial
       Services Departments.
Title: Process for In-Patient and Out-Patient Cancelled             Date          Page        Policy #
       Procedures                                                   Issued:       2 of 6      MR.20
                                                                    5/3/10

IV.    Policy
       A. The documentation must include the extent of the procedure performed, the reason for the
          cancellation and the location of patient when the procedure was cancelled.
       B. Patient Management Services Planner will review medical record and/or case data and will
          speak to Physician about whether patient will be rescheduled for procedure.
       C. Health Information must receive the original paper medical records for coding and storage.
       D. For electronic documentation changes, refer to Surginet User Manual.


V.     Procedure
       A.       Registration/Charging/Coding/Guidelines
                All Patient Type changes and/or cancellations for any and all outpatient accounts may
                only be completed by designated personnel who have been given security access to
                perform this function. Security for all cancellation functions in the patient management
                system(s) will be limited and will only be given upon the approval of the Patient Access
                Site Supervisors in collaboration with the Manager of Revenue Audit Process and the
                Quality Enhancement team.

                The following coding/charging procedures should be followed when an outpatient
                procedure is a “no show” or has been cancelled after the patient presents to the facility.

                1.     If a pre-clinic visit has been created for a patient and the patient does not
                       arrive (“no show”) for their visit (including cancellation or rescheduling of
                       their appointment):

                       a.      Ambulatory/Outpatient Surgery Unit
                               1)   The unit secretary or designee verifies that the patient is a “no
                                    show”.
                               2)   The patient’s pre-clinic visit is not upgraded.
                               3)   The system will automatically cancel pre-clinic visits not updated
                                    five (5) days after the scheduled date.
                               4)   All paperwork, including the PLUE (Patient Link-Up Enterprise)
                                    packet and any clinical documentation that has been prepared
                                    (i.e. history and physical, lab results, etc.), should be forwarded to
                                    HIM (Health Information Management) with the words “no show”
                                    written on the PLUE (Patient Link-Up Enterprise) label and/or face
                                    sheet. However, if the service has been rescheduled within
                                    30 days (from the date of the history and physical), the
                                    department should maintain the original clinical
                                    documentation in their files until the rescheduled date.
                               5)   If the patient’s visit is being re-scheduled, do not reuse the
                                    scheduling system number. A new entry in scheduling system
                                    must be done and a new number generated.
                               6)   If the patient’s visit is being rescheduled, do not reuse the same
                                    financial number. A new pre-registration must be done and a new
                                    financial number generated.

                       b.      Health Information Coder
                               1)     No diagnosis or procedure codes are assigned by the coder in this
                                      scenario.
Title: Process for In-Patient and Out-Patient Cancelled          Date         Page        Policy #
       Procedures                                                Issued:      3 of 6      MR.20
                                                                 5/3/10

                       c.     Quality Enhancement
                              1)     Reviews no show account and removes any inappropriate
                                     charges.

               2.      If procedure is cancelled following the patient being placed in a bed, but
                       prior to the patient being placed in the procedure room (pre-op/holding
                       area):

                       a.     Ambulatory/Outpatient Surgery Unit
                              1)   The unit clinical staff assesses the patient and the procedure is
                                   cancelled.
                              2)   The unit posts the following charges: cancellation counter code
                                   and ambulatory surgery pre charge. The clinical staff documents
                                   within the medical record (on the “Ambulatory Procedure Record”)
                                   the intended procedure, the reason for the cancellation of the
                                   procedure and the location of the patient at the time the procedure
                                   was cancelled.
                              3)   The unit staff will also notify the patient of the potential status
                                   change and ask the patient to sign the Change of Status form
                                   prior to discharge
                              4)   The Patient Management Planner is notified by the Procedural
                                   Unit that the procedure has been cancelled. After conferring with
                                   the Physician, the Planner will complete a LOA form, if applicable.
                                   The original LOA form should be left in the medical record, a copy
                                   should be sent to Quality Enhancement, and a copy maintained by
                                   the Planner. The Planner will also notify the patient of a potential
                                   status change and ask a patient to sign a form with that
                                   notification. This form should also remain in the medical record.
                              5)   All paperwork, including the PLUE packet and any clinical
                                   documentation that has been prepared (i.e. history and physical,
                                   lab results, etc.), should be forwarded to Health Information
                                   Management with the words “patient presented-cancelled
                                   procedure” on the face sheet.
                              7)   There must be written documentation in the record about the
                                   reason that the procedure was cancelled (for example: patient’s
                                   blood pressure elevated- surgery postponed.). This should be
                                   written and signed by the Attending Physician.
                              8)   If the patient’s visit is being re-scheduled, do not reuse the
                                   surgery scheduling system number. A new entry in the surgery
                                   scheduling system must be done and a new number generated.
                              9)   If the patient’s visit is being rescheduled, do not reuse the same
                                   financial number. A new pre-registration must be done and a new
                                   financial number generated.

                       b.     Health Information Coder
                              1)     If the status change form that has been completed by the unit and
                                     signed by the patient is included in the record, the registration
                                     type will be changed to SDC
                              2)     The patient type for this record should be SDC.
                              3)     Review the documentation within the medical record for reason for
                                     cancellation.
Title: Process for In-Patient and Out-Patient Cancelled            Date          Page        Policy #
       Procedures                                                  Issued:       4 of 6      MR.20
                                                                   5/3/10

                              4)      Code only the principal diagnosis (reason for surgery), the
                                      appropriate V code
                                          for the reason for the cancellation and any secondary
                                      diagnoses.
                              5)      Do not code any procedure code(s) or modifier(s)

                       c.     Quality Enhancement
                              1)     If ancillary services were performed, the QE Analyst must review
                                     the reason for the cancellation (V code assigned by coder) to
                                     determine if ancillary only charges (lab, x-ray, EKG etc) are to be
                                     billed without a procedure charge. QE will be reviewing a daily
                                     report to identify accounts with V codes attached.

               3.      If the procedure is cancelled when the patient is in the actual procedure
                       room, but prior to anesthesia being administered:

                       a.     Ambulatory/Outpatient Surgery Unit
                              1)   The clinical staff documents within the medical record (on the
                                   “Perioperative Record”, “Universal Protocol Form” and/or “Nursing
                                   Procedure Record”) the intended procedure and the reason for the
                                   cancellation of the procedure.
                              2)   The unit posts the following charges: ambulatory surgery pre
                                   charge and OR per minute charge for the time the patient was in
                                   the procedure room (based on OR start time). NOTE: The
                                   Ambulatory Surgery Center posts charges as appropriate for
                                   the procedure.
                              3)   The entire medical record must be sent to Health Information
                                   intact.

                       b.     Health Information Coder
                              1)     If the status change form that has been completed by the unit and
                                     signed by the patient is included in the record, the registration type
                                     will be changed to SDC.
                              2)     Review the medical record for reason and the location of the
                                     patient at the time the procedure was cancelled.
                              3)     Code the principal diagnosis (reason for surgery), the appropriate
                                     V code for the reason for the cancellation and any secondary
                                     diagnoses.
                              4)     Also code the intended CPT/HCPCS procedure code and attach
                                     modifier – 73.

                       c.     Quality Enhancement
                              1)     If the ancillary services were performed, the QE Analyst must
                                     review the reason for the cancellation (V code assigned by Coder)
                                     to determine if ancillary only charges (lab, x-ray, EKG, etc) are to
                                     be billed without a procedure charge.

                              2)      QE will be reviewing a daily report to identify accounts with V
                                      codes
Title: Process for In-Patient and Out-Patient Cancelled             Date          Page        Policy #
       Procedures                                                   Issued:       5 of 6      MR.20
                                                                    5/3/10

               4.      If the procedure is cancelled once the patient is in the procedure room, and
                       after anesthesia is administered:

                       a.     Ambulatory Surgery Unit/OR
                              1)   The clinical staff documents within the medical record (on the
                                   “Operative Report”, “Perioperative Record”, “Anesthesia Record”,
                                   “Universal Protocol and physician “Progress Notes”) the reason
                                   for the cancellation of the procedure and the extent of the
                                   procedure performed.
                              2)   The unit posts the following charges: ambulatory surgery pre
                                   charge, OR per minute charge for the time the patient was in the
                                   procedure room (based on OR start time,) anesthesia charges
                                   and the PACU per minute charge.
                              3)   The entire medical record should be sent to Health information
                                   intact within 24 hours of the service.

                       b.     Health Information Coder
                              1)     Outpatient Accounts:
                                     a)     Review the medical record for reason and the location of
                                            the patient at the time the procedure was cancelled. The
                                            accounts should reflect SDC.
                                     b)     Code the principal diagnosis (reason for surgery), the
                                            appropriate V code for the reason for the cancellation and
                                            any secondary diagnoses.
                                     c)     Also code the appropriate CPT/HCPCS procedure code
                                            and attach Modifier -74.

                              2)      Inpatient Accounts:
                                      a)     If the patient type was in-patient, review the procedure
                                             code to determine if “in-patient–only”. If so, patient type
                                             should remain as in-patient.

                       c.     Quality Enhancement
                              1)     If ancillary services were performed, the QE Analysts must review
                                     the account for adjustments. Process the patient’s claim
                                     accordingly. (For outpatient accounts all diagnostics should be
                                     billed. Inpatient accounts should be adjusted accordingly).


               5.      Additional Notes for Health Information Coders:
                       a.     Definitions of modifiers 73 and 74:
                              1)      73 – procedure is cancelled after patient is in the actual procedure
                                      room, but prior to anesthesia.
                              2)      74 – procedure is cancelled after the administration of anesthesia.

                       b.     Modifiers 73 and 74 should be assigned for all payers.
                              To determine the appropriate assignment of diagnosis/procedure codes
                              and modifiers, the Health Information coder will review the documentation
                              within the patient’s medical record.
Title: Process for In-Patient and Out-Patient Cancelled                                  Date              Page            Policy #
       Procedures                                                                        Issued:           6 of 6          MR.20
                                                                                         5/3/10


VI.       Protocol – N/A


VII.      Documentation
          A.        The documentation within the medical record must support the assigned codes.

          B.        All cancelled procedure charts that are coded & billed are to be maintained in the
                    permanent file area within each Health Information department. Health Information
                    should receive the original medical records from the outpatient units.

          C.        It is the responsibility of the outpatient unit and the operating physician to ensure the
                    proper documentation is provided within the record.


VIII.     Teaching Protocol – N/A



IX.       References
          Surginet User Manual




Kaleida Health developed these policies and procedures in conjunction with administrative and clinical departments. These documents were
designed to aid the qualified health care team in making clinical decisions about patient care. These policies and procedures should not be
construed as dictating exclusive courses of treatment and/or procedures. No health care team member should view these documents and their
bibliographic references as a final authority on patient care. Variations of these policies and procedures in practice may be warranted based
on individual patient characteristics and unique clinical circumstances. Please contact the print shop regarding any associated forms.

								
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