Discontinued Procedures
Per ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021, section B3.3 instructs to code the procedure to the root operation performed if the intended procedure is discontinued or otherwise not completed. Furthermore, the code root operation Inspection of the body part or anatomical region inspected should be reported if a procedure is discontinued before any other root operation is performed.
Q: A 27-year-old patient with known history of intravenous drug abuse and asthma is admitted for acute hypoxemic respiratory failure secondary to severe asthma exacerbation. Per ED provider’s notes, the patient was coughing up large amounts of phlegm with a possibility of aspiration. Thus, the patient was intubated, and bronchoscopy was performed. Bronchoscopy findings showed that there were inflammations of bronchial mucosa, and both lungs with the presence of secretion were suctioned. However, the procedure was aborted because of significant desaturation and evidence of bronchospasm. (Coding tip: suctioning of the secretions was performed prior to the discontinuation of the procedure, so it should be coded to the root operation “drainage.”)
A: 0BH17EZ, insertion of endotracheal airway into trachea, via natural or artificial opening and 0B9M8ZZ, drainage of bilateral lungs, via natural or artificial opening endoscopic
Reference: ICD-10-PCS Official Guidelines for Coding and Reporting Section B3.3 Discontinued or incomplete procedures
