An outpatient hospital procedure is canceled after anesthesia consent but before incision, yet the EHR charge router still posts the case as performed. What should the coder validate?
Select an answer to reveal the explanation.
Short Explanation
Consent is not the same as cutting. If the case was canceled, do not let a hungry charge router bill it as done. Validate performed versus canceled in the op/nursing record before any procedure code drops.
Full Explanation
Outpatient facility coding and charging require confirmation that a procedure was actually performed. Cancellation after preparation or consent does not equal a completed operative procedure for coding purposes, though limited services actually rendered may be reportable under specific rules. Coders must reconcile EHR charge posts with operative, nursing, and anesthesia documentation and suppress incorrect 'performed' charges. Scheduler block time or preference-card defaults are not proof of performance.