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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 5. Ambulatory Surgical Center and Hospital Ambulatory Surgical Center : 5.2 Services/Benefits, Limitations, and Prior Authorization : 5.2.2 Incomplete Surgical Procedures

When an ASC or HASC bills Texas Medicaid for an incomplete surgical procedure, one of the following must be included on the claim:
Claims that are submitted with diagnosis code V641, V642, or V643 or with modifier 73 or 74 are suspended for review of the medical documentation that was submitted with the claim. Providers must submit the operative report, the anesthesia report, and state why the operation was not completed.
Reimbursement to ASC and HASC facilities for canceled or incomplete surgeries because of patient complications is made according to the following criteria, based on the extent to which the anesthesia or surgery proceeded:
Reimburse at 0 percent of ASC 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 preoperative procedures are not reimbursed.

Texas Medicaid & Healthcare Partnership
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