Complication of procedure

cocellococello
edited May 2016 in CDI Talk Archive
Hi Everyone! This is my first posting to CDI Talk but I have been following most of the conversations for a few weeks now and I have thoroughly enjoyed the variety of subjects and information. It is (almost) refreshing to see that no matter where you live, the east coast, the west coast, or parts in between, we all seem to be facing the same challenges! My current challenge er question is this: What is your CDI department's policy in regards to including the verbiage, "complication of procedure" or "post operative complication" ON your queries? Thanks in advance for all your input.

Colleen Ocello, RHIT
Clinical Documentation Specialist
Presbyterian Intercommunity Hospital
Whittier, California
562.698.0811 Ext 12915 or Vocera
cocello@pih.net

"I've learned that people will forget what you said, and
people will forget what you did, but people will never
forget HOW YOU MADE THEM FEEL."

~Maya Angelou

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    We use language that includes 'complication of care' as one of the
    possible responses on certain forms. We are 'transparent' in this
    regard.



    I



    Paul Evans, RHIA, CCS, CCS-P, CCDS



    Supervisor, Clinical Documentation Integrity, Quality Department

    California Pacific Medical Center

    2351 Clay #243

    San Francisco, CA 94115

    Cell: 415.637.9002

    Fax: 415.600.1325

    Ofc: 415.600.3739

    evanspx@sutterhealth.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We do not specifically say "complication". We state what procedure the patient had and when it occured as well as what is documented in the record that is possibly a complication (Ex: "ileus" "Nausea and vomiting", "Resp failure", etc). Then, we query for a link with the following options:


    * Diagnosis was likely directly related to the surgical procedure

    * Diagnosis was likely unrelated to the surgical procedure

    * Other __________________________________

    * Unable to determine


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I should add that we have a query that is specific to Ileus that was drafted with the help of our general surgeons. This one does state "complication" with the following options:

    ... Complication of a surgical procedure.
    ... Severity and Duration consistent with the expected result of a surgical procedure.
    ... Related to Medication (narcotics/anticholinergics/etc)
    ... Unable to Determine
    Other __________________________________________________________


    The verbiage is a tough issue. It's sticky because I do not even think that the term "complication" means the same thing for every person in every circumstance. For instance the hospitalization may be complicated by resp failure that occurred after surgery but that doesn't mean that "complication" was the result of surgery. I think however you phrase it, the most important thing is to be clear that you are establishing a direct link between the "complication" and the surgery. Just because it occurs after/during surgery does not mean there is a causal relationship.
    We have had the opportunity to discuss this issue fairly extensively with our surgeons (for the most part) so I think they (kinda) understand the complexity.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Here is a query devised for postsurgical ileus - it is a form of a
    'reverse query'. The use of the term 'postoperative ileus' is
    particularly problematic during the recovery period from surgery. I
    think the attachment will speak to many issues if you care to review.



    Paul









    Paul Evans, RHIA, CCS, CCS-P, CCDS



    Supervisor, Clinical Documentation Integrity, Quality Department

    California Pacific Medical Center

    2351 Clay #243

    San Francisco, CA 94115

    Cell: 415.637.9002

    Fax: 415.600.1325

    Ofc: 415.600.3739

    evanspx@sutterhealth.org

  • cocellococello
    edited May 2016
    Katy, do the docs respond? Do they answer the queries, and if so, do you feel they answer honestly? Are there any repercussions if they don't answer?
    I really appreciate all the great feedback! Thanks Paul, for your sample query---much appreciated and very helpful.

    Colleen Ocello, RHIT
    Clinical Documentation Specialist
    Presbyterian Intercommunity Hospital
    Whittier, California
    562.698.0811 Ext 12915 or Vocera
    cocello@pih.net

    "I've learned that people will forget what you said, and
    people will forget what you did, but people will never
    forget HOW YOU MADE THEM FEEL."

    ~Maya Angelou


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    They do answer, for the most part and I think they appreciate the opportunity to clarify themselves. Whenever I query for a complication, I pretty much always get a response. I will admit our complication rate is low though, and I'm betting it's not because they don't happen. We have had many conversations, especially with our general surgeons about this particular issue and I think this has really helped.

    Good luck!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

Sign In or Register to comment.