The operative schedule lists a laparoscopic cholecystectomy, but documentation shows the case was cancelled in pre-op and never performed. What is the correct coding approach for that procedure?
Select an answer to reveal the explanation.
Short Explanation
A cancelled case that never started is not a performed procedure. Schedules and “planned” entries are not codes. Code what the team actually did—nothing more.
Full Explanation
Facility procedure coding requires that the procedure was performed as documented. Planned or scheduled procedures that were cancelled and never begun are not reported as completed operative services. Coders distinguish planned-versus-performed entries during abstraction and omit cancelled, non-performed procedures from final coding.