Post Op Ileus
Looking for documentation options for patients who have had a GI surgery and the bowel function has not returned yet, however this is not unexpected. We are having providers call this post op ileus and then they look like there was a complication to the procedure, but really its not a complication. What terminology has anyone instructed providers to use to avoid a complication code and accurately document what is going on with the patient? We know that we can code ileus but even this will make their stats look like a complication because this is an N for POA.
Comments
QUERY: Request for Documentation Clarification - Bowel Function
The documentation in the ________________section of the medical record on__________ (insert date) is as follows:
PHYSICIAN/PA/NP Responses may include:
There is no clinically significant bowel disorder present
Ileus is present and was either monitored/evaluated, treated, extended the length of stay, or lead to increased nursing care, but is expected and is being managed and is not a complication
Ileus is present and related to the procedure, and should be considered a complication as it is unexpected or prolonged beyond the expected period in accordance with the NSQIP Definition.
Other: (Please Specificy/Document):
Definitions
NSQIP Definition- Prolonged Postoperative Ileus: Patient with an ileus managed with a nasogastric tube and/or the patient is NPO for ≥ postoperative day 3.
Note: The patient must be on strict NPO status (NPO w/ ice chips or sips does not count)
Postoperative Ileus - Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus. (Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [Medline].)
Definitions Below from Stedman’s
Ileus- Mechanical, dynamic, or adynamic obstruction of the intestines; may be accompanied by severe colicky pain, abdominal distention, vomiting, absence of passage of stool, and often fever and dehydration
Adynamic Ileus - obstruction of the bowel due to paralysis of the bowel wall, usually as a result of localized or generalized peritonitis or shock
Dynamic Ileus - intestinal obstruction due to spastic contraction of a segment of the bowel
Mechanical Ileus - obstruction of the bowel due to some mechanical cause, e.g., volvulus, gallstone, adhesions
Rose: In my opinion, not all patients after surgery will have an ileus that meets the guidelines you recited above, which are the basis for reporting a condition. If a true ileus is present, but it not stated as a 'complication', I code the ileus, but NOT as a complication. Very controversial and very nuanced...must ensure this is a true ileus and not just 'waiting for expected return of bowel function in the typical recovery period'.
Paul Evans, RHIA, CCDS