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

Comments

  • edited April 2016
    Ann,
    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
  • Tough one - Coding Clinic clouded the waters on this, in my opinion. But, and this is MY opinion, if the record states the 'ileus' is expected and the ileus does not o/w meet criteria as a complication, or even meet criteria for reporting at all (see NSQIP, for example), it should not be coded at all. To do so is to unfairly 'ding' a surgeon with a 'complication. Personally, I'd rather maintain my credibility with the physicians rather than strictly follow this poorly written advice from Coding Clinic.


    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
  • edited April 2016
    Thanks well see what the powers that be say. I appreciate the input.
    Ann

  • I can only repeat is a misclassification to label 'any/all' ileus that occur following G/I surgery as a complication, and I say that having digested that particular advice from Coding Clinic....this is why we need more physicians on the Editorial Board for Coding Clinic.



    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


  • edited April 2016
    Paul,
    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
  • I agree with your interpretation...if it o/w meets any of the reporting requirements per UHDDS, it should be coded, but probably 'only' as 560.X, 'simple' ileus and not as a complication.

    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
  • edited April 2016
    Underlying all of this...don't we need the physician to create the link to the surgery in order to have a cause/effect? There are coding clinics that guide us for complications to not assume a link. I don't think the coding clinic overrides the provider's given opinion for ileus either. There is the paralytic ileus 560.1 option.

    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network
    ail and destroy this message.
  • It seems this is an example whereby Coding Clinic has been 'consistently inconsistent' and has offered confusing and even contradictory advice....worrisome considering the technical nature.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • This is generally true but in this specific case the coding clinic (right or wrong) has said this is not needed. The statement at the bottom of the coding clinic posted says:

    "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
  • Katy: Nicely stated and all true - which would make me feel even worse were I to blindly follow the Index and assign the code in the manner directed. We are more likely to ding the most cooperative surgeons, whilst others slip under the radar and outcomes data can be skewed.




    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • Yes, We have seen this with many quality measures from inhospital falls to post-op complications. Those facilities that are open to ethically reporting falls will appear 'worse' than those who simply do not report, etc... In a climate where quality data is increasingly avaialable as well as ties to reimbursement, this is highly problematic. Until they start aggressively auditing low-outliers, I think this will continue.

    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
  • The coding clinic question/answer was about a patient that had surgery one week ago & was readmitted with an ileus. It sound to me that when the CC say " In this case the alpa Index takes precedence'" it is referring to readmission with ileus rather than an expected ileus immediate post-op period. So I think you you could fight this especially with the docs good documentation.

    Janice Davis, RN, CCDS
  • edited April 2016
    Thank you it's all I can think about (sadly :) ).

    I really like this point and soooo appreciate Katie and Paul's as well.
    Ann

    Sent from my iPhone
  • What a great conversation!
    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

  • edited April 2016
    I think this is a great point!
    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
  • edited April 2016
    Just to clarify one thing-- the surgeon DID NOT use the word POST OPERATIVE at all. That is one of my big points of contention.

    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.


  • edited April 2016
    Yes, I wasn't referring to your specific case, just in general since this is just an area that I find interesting and especially problematic. I also agree that an expected ileus should not always be a complication but if I was to play the devils advocate here I would say that if its within the expected 3-5 days post-op and truly a normal expectation of this particular case, there is the question of whether it should be coded at all. If it does not impact care beyond what would be expected for anyone undergoing this procedure should it be coded? I honestly don't know... Then again, that would also mean that our expected acute blood loss anemia should likely not be coded on most of our cardiothoracic surgery patients...

    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

  • edited April 2016
    I think the real problem is the lack of consistency-
    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
  • edited April 2016
    Hahaha. You may be right ;-)

    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
  • Hi All,
    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?
  • edited April 2016
    I'd love to see the reference?
    thanks

    Ann
  • This is a complication code.

    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

  • edited April 2016
    I just was reminded of this from 'avoid the push and pull when reporting complications of surgery' on the ACDIS site and thought it may be helpful...

    '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
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