postoperative abscess

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I have a patient who was admitted 2 wks post appendectomy (ruptured) for a 'postoperative abscess'. Do I need to query for clarification of the abscess as a complication of surgery? I always struggle with these ones because the encoder/index will route to the complication code because of the 'postoperative' but then there is also guidance that the MD MUST make the connection.

Thanks!

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

  • jolene.filejolene.file
    edited April 2016
    Hi Katy!
     
    In my opinion, it would depend on the PMH and current history which is documented in the record giving detail of the the postop abscess.   If you can't tell whether the abscess just occurred in the postop period or if was related to the surgery with  a condition such as  a seroma, sepsis, wound infection, I would query. 
     
    Hope that is helpful.
     
    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    You mentioned a ruptured appendix … makes me think it might be worth a query to clarify if the abscess was felt to be a complication of the surgery or solely a consequence of the PRE-operative ruptured appendix
    Does this make sense?

    If there wasn’t the ruptured appendix with contaminated abd …. Would probably not query (as the clinical story in that scenario I suspect would pretty clearly support an operative complication).

    Don

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