Surgical or other procedure not carried out because of patient's decision

This code indicates that a planned surgical operation or other medical procedure was not performed because the patient, after being informed, chose to decline the intervention. It signifies a patient's autonomous decision to refuse recommended treatment, even if medically indicated.

Use this code when a physician documents a patient's refusal of a proposed surgery, diagnostic procedure (e.g., biopsy, endoscopy), or therapeutic intervention (e.g., chemotherapy, radiation) that was otherwise scheduled or strongly recommended. This applies when the procedure was not carried out solely due to the patient's informed choice.

• Always ensure physician documentation explicitly states the patient's refusal as the reason for the procedure not being performed.
• Do not use this code if the procedure was cancelled due to physician decision, facility issues, or patient no-show without documented refusal.
• This code is for the reason the procedure was not carried out, not for the procedure itself.