Proc/trtmt not crd out bec pt decision for unsp reasons

This code indicates that a planned medical procedure or treatment was not performed because the patient, or their authorized representative, made a decision to decline it. The specific reason for the patient's refusal is not documented or is unknown. This code signifies a patient-initiated cancellation of care.

Use this code when a patient explicitly refuses a recommended procedure, surgery, diagnostic test, or therapeutic intervention, and the medical record does not specify the reason for their decision. This often occurs when a patient simply states "no" or "I don't want it" without further explanation. It is appropriate when the provider has documented the patient's refusal but not the underlying rationale.

• Ensure documentation clearly states the patient's decision to decline the procedure/treatment.
• Only use this code when the reason for refusal is genuinely unspecified in the medical record.
• Do not use if the patient's decision was due to a medical contraindication, lack of facility resources, or provider decision.