Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4. Outpatient Hospital (Medical/Surgical Acute Care Outpatient Facility) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.3 Day Surgery : 4.2.3.6 Incomplete Day Surgeries

4.2.3.6
When HASC providers submit claims to Texas Medicaid for an incomplete surgical procedure, one of the following must be included on the claim:
Modifier 74 for a discontinued outpatient procedure after anesthesia administration or 73 for a discontinued outpatient procedure prior to anesthesia administration.
Claims that are submitted with diagnosis codes V641, V642, V643 or modifier 73 or 74 suspend for review of the medical documentation submitted with the claim. Providers must submit the operative report, the anesthesia report, and state why the operation was not completed.
Reimbursement to HASC facilities for canceled or incomplete surgeries because of patient complications, is made according to the following criteria, depending on the extent to which the anesthesia or surgery proceeded:
Reimburse at 0 percent of HASC group payment schedule for a procedure that is terminated for nonmedical or medical reasons before the facility has expended substantial resources.
Surgeries canceled because of incomplete pre-operative procedures are not reimbursed.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.