Questions and Answers
• If a procedure is discontinued before any other root operation is performed, code the root operation “______” of the body part or anatomical region inspected.
Inspection
• A patient is admitted for transurethral removal of ureteral stone. The scope is passed as far as the bladder, but the surgeon is unable to pass it into the ureter. Code only “______” of the bladder.
Inspection
• A planned aortic valve replacement procedure is discontinued after the initial thoracotomy and before any incision is made in the heart muscle when the patient becomes hemodynamically unstable. This procedure is coded as an open “______” of the mediastinum.
Inspection
• When a procedure is considered to have “failed” in that it did not achieve the hoped-for result or because every objective of the procedure could not be accomplished, the procedure is coded as ______.
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• It is important to distinguish a failed procedure from an attempted but unsuccessful procedure. In the example of the percutaneous coronary angioplasty, the procedure was performed, so the “______” is coded.
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What should be coded if a planned procedure is discontinued before any other root operation is performed?
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How should a discontinued procedure be coded if the intended procedure is not completed?
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If a procedure is considered to have 'failed', how should it be coded?
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What should be coded if a procedure is attempted but is not successful?
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In the case of an almost immediate reocclusion of the coronary artery after a percutaneous coronary angioplasty, how should the procedure be coded?
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Study Notes
Discontinued Procedures
- If a procedure is discontinued before any other root operation is performed, code the root operation "Inspection" of the body part or anatomical region inspected.
- If a procedure is abandoned before the intended objective is achieved, code the procedure as if it were completed, even if it did not achieve the desired outcome.
Examples of Discontinued Procedures
- If a transurethral removal of ureteral stone procedure is discontinued after the scope is passed as far as the bladder, code only "Inspection" of the bladder.
- If a planned aortic valve replacement procedure is discontinued after the initial thoracotomy and before any incision is made in the heart muscle, code an open "Inspection" of the mediastinum.
Failed vs Unsuccessful Procedures
- A "failed" procedure is coded as if it were completed, as long as the procedure was performed, even if it did not achieve the desired outcome.
- An "unsuccessful" procedure is distinguished from a "failed" procedure, and is coded as if it were completed, as long as the procedure was performed.
Specific Scenarios
- In the case of an almost immediate reocclusion of the coronary artery after a percutaneous coronary angioplasty, code the "Dilation" of the coronary artery, as the procedure was performed, even if it did not achieve the desired outcome.
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