APL

We are increasing our involvement with PSI's and (of course) are biggest problem area is Accidental Puncture and Laceration. I audited our cases for the last year and basically found issues across the board.

1. Lack of queries from CDI for clarification

2. Poor physician documentation

3. Coding assigning every Lac/punc as a complication.

I would welcome thought/ideas on how you have approached this topic as we try to hit it head on. I attended severeal conference sessions on the topic so I feel I have decent background but I would love to hear real solutions.

Specifically, I would love to hear back on a few things:

1. What 'shoulc' happen when a lac is mentioned but not stated as a complication? Obviosuly I know a query should be placed, but what if it is not placed? Is the default to code is as a complication? My understanding is that physicians must state that a complication is a complication in order for it to be assigned as such. However, this is not what I am seeing in the data across all our coding staff.

2. What terminology are you recommending physician s to sue when a lac occurred but is not a complication? Integral? Inherent?

3. How are you/have you educated your coders and physicians?

4. What would you do with this scenario?

"There was great care taken to avoid injury to the bowel that was directly underneath the skin. She did have a chronic wound that had been present since her last surgery in the left anterior abdominal wall. This in fact was the serosa of a small intestine. There was no way to avoid injury and serosal tear. This enterotomy was oversewn using 3-0 Vicryl suture.



She had extensive dense adhesions. Lysis of adhesions using Metzenbaum and electrocautery required over 2 hours. Once this was done there was another enterotomy that was made. Decision was made to resect these 2 areas. This was done using Endo GIA stapling device, 75, and then 2 side to side anastomoses were performed using a 75 GIA stapler and then a TA 60 was used to close the enterotomies. Of note, the bowel, the central portion was quite dilated consistent with prolonged obstruction. Patient had been having significant abdominal pain preoperatively as well as some nausea as well.



Complication or not?


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

  • edited April 2016
    Our previous CMO required both CDI and Coders to query ANY possible complication for clarity because our complication rate was high. If CDI misses the opportunity, it is up to coder's to place a retro-query for clarification. It helps having administrative buy-in and our complications rates have decreased.

    Julie Cruz RN, CDS
    Clinical Documentation Specialist
    St. Joseph Health
    Eureka, CA 95501

  • edited April 2016
    We have bit different approach here. All coders have these cases with potential complication placed on hold till one of our HIM directors reviews it. Then, if she agrees that it is "true" complication, she would send this to Director of Medical Affair. They review it and give their point of view. If necessary, CDI will go ahead and place a query whether this considered as Inherent/integral part or it's a complication. If everyone agrees on complication, coder the will drop the chart. Very comprehensive process, but since now we have this process in place, coders would not just assign complication code without anyone looking at the chart. If this was one of CDIS case, they are supposed to query the surgeon. We have lots of educational sessions with coders and CDIS, and we had Dr. Gold's verbal presentation on this.
    In this case , we would not assign a complication since Dr. Stated that it was unavoidable.
    Anna
    (954)265-6974 (work)
    (954)558-0739 (cell)
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 03, 2015 11:11 AM
    To: Rozhkovskaya, Anna
    Subject: RE:[cdi_talk] APL

    Our previous CMO required both CDI and Coders to query ANY possible complication for clarity because our complication rate was high. If CDI misses the opportunity, it is up to coder's to place a retro-query for clarification. It helps having administrative buy-in and our complications rates have decreased.

    Julie Cruz RN, CDS
    Clinical Documentation Specialist
    St. Joseph Health
    Eureka, CA 95501

  • edited April 2016
    One thing you need to keep in mind with complications is that you are coding it for the patient not the physician. The fact that it is a quality indicator or the physician may get "dinged" because of it doesn't mean you don't code it. Was it a complication for the patient? If the physician says it was unavoidable that doesn't mean you don't necessarily not code it because it was still an issue for the patient. There are many good webinars out there on complication coding and it is a tough subject.

    Key words to use in a query are "Was this expected or is this to be considered a complication? Please indicate if this occurred postop/intraop"


    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Good Samaritan Health System
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436



  • While I agree that this is true, the code includes the term 'accidental'. If the enterotomy was not an accident but was expected due to that patients physiology or the complexity of the procedure, it is not an accident. Correct?

    http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/

    I also think you have to consider your question 'was it a complication for the patient' carefully. Many APL's that ultimately do not impact the patient (LOS, nursing case, etc) may still be a complication by the surgeon if we really are talking about an 'accidental' puncture/lac.

    This topic is very sticky and clinically complex which is why I ultimately believe the surgeon needs to determine whether an punc/lac is truly a complication.


    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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