PSI - 15 patient safety indicator report
I have a question about an issue involving quality, documentation and proper coding. The Quality PSI-15 (patient safety indicators) report is inclusive of the ICD-9 Accidental Puncture or Laceration diagnosis codes :
Accidental cut, puncture, perforation, or hemorrhage during medical care E8700 to E8709, and 998.2.
I would like to give an example of a case… An inpatient has an indwelling foley catheter inserted, for example, the patient has urinary retention. After insertion of this foley catheter, the patient develops hematuria. Documented in the chart is that the patient had a “traumatic foley insertion†with hematuria. The comorbidities of this particular case are that the patient has thrombocytopenia, or even perhaps a case where a patient is on a Heparin drip, or even a patient that has no secondary diagnosis that might have caused hematuria. No specific urethral or other injury is documented as a result of the foley insertion. A urology consult is called and documents that the patient has hematuria sec to traumatic foley insertion, will follow up urinalysis as an outpatient with no mention of an injury occurring as a result of the foley inserted.
My question is about the proper code assignment for this event of insertion of a foley resulting in hematuria.
Should this be coded as a complication of the procedure, urinary catheter as the cause of abnormal reaction of patient or of later complication, without mention of misadventure at time of procedure which would be an E879.6 code along with ? 997.5 code, OR should this be coded as a secondary code of E870.8 (accidental puncture, cut , perforation, or hemorrhage during other specified medical care?
My thoughts are that the E870.8 code would not be used as this seems like an event of a complication of a procedure, and not specified as an injury to the urethra. I spoke to a urologist on this issue, and his opinion is that hematuria after a traumatic foley insertion is very common, and it rarely indicates injury to the urethra.
It seems like the code E970.8 should not include hematuria related to traumatic foley insertion as being on the same report as 998.2 accidental laceration or puncture during a bowel resection.
Accidental cut, puncture, perforation, or hemorrhage during medical care E8700 to E8709, and 998.2.
I would like to give an example of a case… An inpatient has an indwelling foley catheter inserted, for example, the patient has urinary retention. After insertion of this foley catheter, the patient develops hematuria. Documented in the chart is that the patient had a “traumatic foley insertion†with hematuria. The comorbidities of this particular case are that the patient has thrombocytopenia, or even perhaps a case where a patient is on a Heparin drip, or even a patient that has no secondary diagnosis that might have caused hematuria. No specific urethral or other injury is documented as a result of the foley insertion. A urology consult is called and documents that the patient has hematuria sec to traumatic foley insertion, will follow up urinalysis as an outpatient with no mention of an injury occurring as a result of the foley inserted.
My question is about the proper code assignment for this event of insertion of a foley resulting in hematuria.
Should this be coded as a complication of the procedure, urinary catheter as the cause of abnormal reaction of patient or of later complication, without mention of misadventure at time of procedure which would be an E879.6 code along with ? 997.5 code, OR should this be coded as a secondary code of E870.8 (accidental puncture, cut , perforation, or hemorrhage during other specified medical care?
My thoughts are that the E870.8 code would not be used as this seems like an event of a complication of a procedure, and not specified as an injury to the urethra. I spoke to a urologist on this issue, and his opinion is that hematuria after a traumatic foley insertion is very common, and it rarely indicates injury to the urethra.
It seems like the code E970.8 should not include hematuria related to traumatic foley insertion as being on the same report as 998.2 accidental laceration or puncture during a bowel resection.