Postoperative ileus
Looking for input on this oh, so fun subject--
I thought and felt that 3M surgical complications supported that ILEUS AFTER SURGERY was not automatically a complication. I thought the relation ship per coding guidelines had to be stated by the provider and if there was a question to query.
I have a case that provider wrote "expected ileus" considering the "massive paradiaphramtic hernia".
I thought this should allow for noncomplication...?
The patient did have an NGT placed for distention but it was removed by POD4 which per 2014 UPTODATE article (and other) references 3-5 days as normal period. The stay was prolonged due to respiratory issues.
Here was my quote from coding:
"You are correct that guidelines do take precedence over coding clinic but in this case the index takes you to this code so we would follow the index first. "
So bottom line even if doctor states ileus is expected (and in this case they never even used the word postoperative) all ileus' after surgery are a complication code??
Paul where are you??
Thanks,
Ann Donnelly
ann.donnelly@sclhs.net
I thought and felt that 3M surgical complications supported that ILEUS AFTER SURGERY was not automatically a complication. I thought the relation ship per coding guidelines had to be stated by the provider and if there was a question to query.
I have a case that provider wrote "expected ileus" considering the "massive paradiaphramtic hernia".
I thought this should allow for noncomplication...?
The patient did have an NGT placed for distention but it was removed by POD4 which per 2014 UPTODATE article (and other) references 3-5 days as normal period. The stay was prolonged due to respiratory issues.
Here was my quote from coding:
"You are correct that guidelines do take precedence over coding clinic but in this case the index takes you to this code so we would follow the index first. "
So bottom line even if doctor states ileus is expected (and in this case they never even used the word postoperative) all ileus' after surgery are a complication code??
Paul where are you??
Thanks,
Ann Donnelly
ann.donnelly@sclhs.net
Comments
I am interested in Pauls response as well. A few years ago I thought the same, we instructed out MD's to document 'expected' ileus's informing them that this would NOT result in a complciation code. Then this CC came out
Postsurgical ileus
Coding Clinic, First Quarter 2012 Pages: 6-7 Effective with discharges: April 1, 2012
Question:
The patient who underwent surgical repair of small bowel obstruction one week ago is now admitted for treatment of an ileus with vomiting. The patient previously had lysis of adhesions secondary to small bowel obstruction. Would it be appropriate to assign code 997.49, Digestive system complication, Other digestive system complications, as the principal diagnosis, or must the provider explicitly document "post-operative ileus"?
Answer:
Assign code 997.49, Digestive system complication, Other digestive system complications, as the principal diagnosis. Code 560.1, Paralytic ileus, should also be assigned to describe the specific complication. The Alphabetic Index provides direction and leads the coder to assign 997.49. This code assignment may be located in ICD-9-CM's Alphabetic Index as follows:
Ileus
following gastrointestinal surgery 997.49
Although in the past Coding Clinic has advised that a causal relationship between the surgery and the condition should be documented, in this case the ICD-9-CM's Alphabetic Index takes precedence.
As far as I know, a post-op ileus will be a complication. That being said, a few presentations regarding complications at the conference caused some confusion for my staff because it seemed like some people thought this was a grey area (as well as having a very strict documentation demaind for causality related to complications in general)
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I am responding w/o re-reading all of the pertinent issues of Coding Clinic. But, note in this example cited from Coding Clini that patient presents AFTER being Discharged and the time frame is stated as a 'week after the procedure'. This certainly does 'sound like' a complication?
However, I believe it is not correct or congruent with medical practice for the Index to 'automatically' take us to a complication simply because an ileus happens 'sometime after' the procedure. This is not consistent with clinical criteria used by surgeons, such as NSQUIP.
Just as we can be lead down the wrong road with the term 'postoperative failure' in a patient that has undergone routine valvular repair and is otherwise simply maintained on MV for a period of time for recovery, and w/o any cardiopulmonary compromise, so too can this code selection be simply clinically incorrect.
My point is reflected in the attachment - many things cause an ileus, and if the ileus is not directly 2/2 bowel manipulation AND if the ileus is not prolonged or severe, it should not be coded at all.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Ann
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I do agree with you that we should look carefully at whether the ileus should be coded at all. Ie: does it meet criteria for secondary dx? In the case where they are just waiting for bowel function to return or something like that, it seems taht it should not be coded. That being said, if the patient required an NG tube or more than the 'usual' level of care for that procedure, it seems it should be coded.
I appreciate your opinion.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
1. Simple Ileus - 560.X
Versus
2. 997.49 (GI Complication) AND 560.X, ileus
This is how "I" personally handle this situation, but others probably differ. I have a real dislike for the way Coding Clinic presented this clinical issue as such advice simply can make the coding profession 'seem misinformed'.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
ail and destroy this message.
Paul Evans, RHIA, CCS, CCS-P, CCDS
"Although in the past Coding Clinic has advised that a causal relationship between the surgery and the condition should be documented, in this case the ICD-9-CM's Alphabetic Index takes precedence."
Just on a theoretical level, I think our reticence to code these as a complication speaks to our (and physicians) fear of the coding of complications. If all physicians and coders coded post-op ileus
Paul Evans, RHIA, CCS, CCS-P, CCDS
As for this case, I think it can be seen both ways. Either we let the MD's make the connection or we determine that the connection is intrinsic. If we make the MD's make the connection, it will be vastly under-reported and likely disproportionately impact
Janice Davis, RN, CCDS
I really like this point and soooo appreciate Katie and Paul's as well.
Ann
Sent from my iPhone
I have been trying to understand the coding/complication considerations for post op ileuses myself.
After reading all of the discussions I know I'm not the only one that finds it confusing!
Greta
Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
If you assign in that fashion, then I thing you just need to make sure the documentation is very clear. I would discourage the statement of 'expected POSTOPERATIVE ileus' if you don’t want to code it as a complication because the index will take the coder directly to the complication code with that terminology and index takes precedent over everything else. I think I would try to encourage the MD's to use just 'expected ileus' or something like that. The debate then becomes about when the an expected ileus should be coded? If it is expected is it 'integral' to the procedure? If not and it only happens occasionally to patient undergoing this procedure then is it a complication?
what we used to do prior to this CC was query the MD for the underlying cause:
complication of surgical procedure
Severity and duration consistent with the expected result of a surgical procedure
Related to medication
Unable to determine
Other
I still struggle with the idea of trying to determine in what circumstances an 'expected' ileus should be coded. I have a sneaky suspicion that if an ileus was the sole CC on a record and the provider stated 'expected post-op ileus' and did not specify that it was due to narcotics or something that this would be an easy target for an auditor to say that it should not have been coded at all. But of course I don’t really know...
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
I do not think "expected"should be coded as a COMPLICATION for sure, if it is within a "normal time frame" which many resources including a 2014 UptoDate article suggests that time frame is 3-5 days for expected ileus. I think this should make it inherent to the procedure and they said it was expected due to the massive paraesophageal hernia present preoperatively.
And I have already queried and got another cc and an mcc on this case. I don't gain a thing here. I just want to be fair to our surgeons. IN this case I did not even query for the expected. The surgeon wrote it on his own.
Complex stuff...
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
how can a complication be automatic in only one diagnosis, but not in another like post operative respiratory failure and the fact the coding guidelines specifically state a complication can not be assumed.
I can definitely see the point from visually looking at the index BUT again it goes back to what you are saying, if it's inherent should it be coded? I think one of the problems is that they chose a 997 code when they added it opposed to the ?? 518? for respiratory failure following surgery (different than post operative respiratory failure) and NOT a complication code.
My honest (probably politically incorrect opinion) someone (s) just messed up and didn't think it through.
Thanks,
Ann
It is strange and definitely inconsistent with the other complications. Its one of those things where if we want to code to the highest specificity we will end up with the complication code because the only way to code it as post-operative. I struggle with the idea of us basically encouraging less specific documentation in an effort to avoid complications but it seems like that's where we are.
I think ideally if all post-op ileus's were coded as complications we would just be 'moving the bar' for what is a normal complication rate for these surgical procedures (since these post-op ileus's will happen with all surgeons). But no hospital wants to be the first hospital to do this because we know not all hospitals will do it and we will end up making our surgeons and our hospitals appear to have a high complication rate.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Please correct me if I am mistaken. But, I bleieve that code 99749 (other digestive system complication), while a 900 code, is NOT a reportable complication. So, it should be fine to code as the Index suggests without concern to your good surgeon's reputation. Thoughts?
thanks
Ann
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
'In addition, many secondary diagnoses are components of a larger disease and thus should not be reported using complication codes. For example, patients with a ruptured bowel generally show up with a tight abdomen, absent bowel sounds, and an elevated white count. Frequently they have ileus and sepsis-and when they come out of the surgery, they still have ileus and sepsis, and remain on antibiotics.
"The question is, was it the surgery that caused the ileus, or the ruptured bowel?" Gold says. If it's the latter, the ileus should not be reported as a complication, but should be reported as present on admission (POA) or clarified for its POA status.
In addition, all surgeries require some degree of routine postoperative treatment, and thus should not be separately reported. For example, patients who undergo abdominal surgery typically don't resume normal functioning of their large intestine for three days after the surgery.
"When the surgeon writes on day one, 'postoperative ileus,' a coder may assign it to get the CC and the surgeons will get inappropriately [penalized] for it," Gold says. Why is a complication code inappropriate in this instance? Paralytic ileus occurs in all patients who have major bowel surgery, he says, and they all get treated the same way.
"There is no additional utilization of resources, or observation, or anything different from the usual major bowel case," says Gold. "It should not be reported at all. It does not meet UHDDS criteria as a valid secondary diagnosis."'
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404