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BILLING AND CLAIMS
Can you charge a cancelled surgery if the patient is not taken to the procedure room?
If the patient has not entered the room, no operating room charges would generate (time in through time out), so there is no charge for the room. We would consider this a cancelled procedure and document the reason why.
If the case is cancelled for clinical reasons after the patient enters the room, the start time is documented, the end time is documented for the time it was cancelled, and the reason would be documented in the medical record. This is chargeable and the CPT on the claim would carry an appropriate modifier.
If the patient enters the room and the procedure is cancelled due to a technical/operational issues outside of the clinical situation of the patient, we would consider the charge process on a case by case basis (generally non-chargeable).
If the patient is not taken to the procedure room, such as the holding area, consider the clinical reasons for cancellation and that the anesthesiologist or surgeon did an assessment. This is an outpatient hospital clinic visit when documented and can be charged. But the actual terminated procedure modifiers -73 or -74 would not apply if the patient is not in the actual procedure room where the procedure is to take place. Also note that local anesthesia is defined as anesthesia for purposes of applying modifier -73 or -74, so the actual procedure room for some procedures may be the exam or clinic and not a full fledged operating room.