Surgical complicaton

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I am currently reviewing an unfortunate case where a patient came in for a roux-en-Y and the surgeon misidentified the bowel initially during the anastomosis , and created and anastomosis from Roux limb to Roux limb. He quickly realized his mistake, and performed a resection of the original anastomosis and re-anastamosized. This is well documented by the physician in the Op note narrative and he also lists it as a complication: Complications: misidentification of bowel at initial anastomosis (jejuno-jejunostomy), requiring resection and re-anastamosis".

How does this complication get coded? The coder is assigning E876.7 (wrong site surgery), a never event as well as 997.9, 998.2, and E870.0. I am not sure this is correct but admit to little experience with this type of scenario.

Any advice would be appreciated.

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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Whoops, 997.9 should be 997.49.

    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

  • martin.conroymartin.conroy
    edited April 2016
    I would code 998.89 E876.8

    Marty

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