Coding expected findings

dog

I am reviewing a chart of a patient who just had major bowel surgery. The postoperative progress note states, "postoperative ileus--to be expected, extensive intraoperative bowel manipulation."

I am wondering if you think this falls under the same guidelines as atelectasis--it's an expected outcome and therefore is rolled into the care paid for by the DRG. Or because it was expected but not mandatory, then I should take it. I hate to add on a complication code when it's not really a complication, even though it's a CC, and I'm also not sure it would meet the definition of secondary dx.

Thx,

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

sbeatty

I'd take it as ileus that is not a post-operative complication, as in
acute expected post-op blood loss anemia-a favorite of our orthopedic
surgeons:).


Sandy Beatty, RN, BSN, C-CDI
Columbus Regional Hospital
2400 E. 17th Str.
Columbus, IN 47201
(O) 812-376-5652 (M) 812-552-6997


"Great leaders are almost always great simplifiers, who can cut through
argument, debate, and doubt to offer a solution everybody can
understand."

General Colin Powell

tiffany_susan

The rule of thumb follow is: if it is inherent to the procedure it is
rolled into the DRG ........... if it requires additional resources to
manage above and beyond the normal..... than it can be taken.

Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System

jolene.file

Unless it is treated, monitored or extends LOS, I would not code.

fentona@bronsonhg.org

I agree with Susan. Inherent of procedure not a complication.
Amy

Amy Fenton, RN
Clinical Documentation Specialist
Clinical Operations Improvement
Bronson Methodist Hospital
601 John Street - Box 59
Kalamazoo, MI 49007
Office: (269) 341-8442
Fax: (269) 341-8330
Pager: (269) 513-3131
E-Mail: fentona@bronsonhg.org

NormaB

If the patient does indeed acquire an Ileus after surgery which extends their LOS and Facility resources - and it is documented - I would code it for the severity and the resouce utilization.

Any other thoughts?

N. Brunson, RHIA, CCDS

digardsk

I usually only pick up the ileus if it is longer than "normal", and requires a treatment. Like, if an NG is (re-) inserted, meds are given for treatment, etc.

sbeatty

This was my intent. I assume (gets me into trouble every time) that we
are always speaking of coding diagnoses that meet the definition of PDx
or "other" diagnoses. This would meet the definition of "other" if after
24 hrs, there is not a change in assessment, at least in my
organization. At that point we go into action with a treatment regimen,
monitoring, and daily physician note addressing the progress toward
resolution or lack thereof. An ileus can significantly extend length of
stay.

Sandy Beatty, RN, BSN, C-CDI
Columbus Regional Hospital
2400 E. 17th Str.
Columbus, IN 47201
(O) 812-376-5652 (M) 812-552-6997


"Great leaders are almost always great simplifiers, who can cut through
argument, debate, and doubt to offer a solution everybody can
understand."

General Colin Powell

Melindascharf

We have had this discussion many times with our coders. If it is documented they will code it (not as a complication) but we will not query for it unless it is longer than anticipated which we have been told is 2-3 days. If it is being treated longer than that with ng, npo, etc than we will query for it. (if not documented)
Melinda Scharf RN, BSN, CCDS
St Joseph Hospital, Orange, Ca

judithbates

I agree. Once they drop an NG, that's additional resources.

sbeatty

We do not code anything as a complication unless the surgeon
specifically states it is a complication.

Sandy Beatty, RN, BSN, C-CDI
Columbus Regional Hospital
2400 E. 17th Str.
Columbus, IN 47201
(O) 812-376-5652 (M) 812-552-6997


"Great leaders are almost always great simplifiers, who can cut through
argument, debate, and doubt to offer a solution everybody can
understand."

General Colin Powell