retained object/equipment malfunction

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Its 3pm on a Friday, so this was bound to happen....

We have a patient that came in septic with a bile duct stone. She had an ERCP and during the ERCP the wire basket off the lithotripsor broke off during the procedure and became lodged in her common bile duct. Because of this, they consulted surgery and they did an open common bile duct exploration andremoved the basket and the stone.

Clearly we have a complication here but is this a mechanical complication or is this a retained foreign body?

There is a discrepancy between quality and coding on this record and I am being asked to weigh in. Quality feels like this was ONE procedure so the body was never 'retained'. However, the ERCP is obviously endoscopic and that ended so that an open procedure could be performed....


I appreciate feedback,

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

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    This great megan! Thank you!

    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

  • idoc3idoc3
    edited April 2016
    I would think this to be one procedure with a complication. I base this on the philosophy that if an endoscopy goes to an open, we bill only for the open (one procedure), although we give mention to the endoscopy. This scenario is similar, the complication was recognized immediately, and I vote one procedure.


    Thanks

    With Best Regards,

    Robert Billerbeck, MD CPC
    Meditco LLC


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    This is how it has been explained to me too. If the foreign object is noted during surgery and removed prior to closure, then its not a retained foreign body. Strange situation because it necessitated an open procedure to remove.

    Thanks for your help!


    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

  • martin.conroymartin.conroy
    edited April 2016
    I have to agree with Traci we would not consider this a retained FB. Also I would only code the open px.

    Marty Conroy
    Temple Health

Sign In or Register to comment.