APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
We are reviewing these cases along with our quality department. When in doubt, we bring the surgeon in to weigh in.
In your case, it sounds almost expected/unavoidable, though the surgeon doesn't use those exact words. My takeaway from lectures on this topic at the ACDIS conference, and the article below, is that it is best to have the MD's state if integral/inherent, necessary and/or unavoidable.
Check out this article from ACS-
http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/
Some highlights-
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the "injury" to a structure is expected, then the surgeon should use language such as:
* "The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed."
* "Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with...."
* "At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers."
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Seekircher, Kerry
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Copyright 2013
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________________________________
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Rozhkovskaya, Anna
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Thanks for your response! I agree that it seems expected but am concerned that coding may not agree. In this case would you query just to make sure?
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 12:41 PM
To: Kathryn Good
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Katy-
We are reviewing these cases along with our quality department. When in doubt, we bring the surgeon in to weigh in.
In your case, it sounds almost expected/unavoidable, though the surgeon doesn't use those exact words. My takeaway from lectures on this topic at the ACDIS conference, and the article below, is that it is best to have the MD's state if integral/inherent, necessary and/or unavoidable.
Check out this article from ACS-
http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/
Some highlights-
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the "injury" to a structure is expected, then the surgeon should use language such as:
* "The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed."
* "Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with...."
* "At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers."
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Seekircher, Kerry
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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We have been looking at PSIs, HACs, and 30 day mortality for a few years now. We have a workqueue that they get fed into pre-bill, post-code that we built with most of the exclusions built into it to avoid looking at accounts that don't apply. One of my CDSs works half time on this, half time on regular CDI duties. Here at UW, if it seems like an unavoidable adverse event, most of the time coding is more comfortable with that spelled out by the docs and the CDS or the coder will query. We kind of take the stance there should be no doubt that this was not a complication for auditing purposes. We are in the arduous process of trying to translate the exclusions into I-10 codes.
Good luck!
Kathy
Kathleen Benson RN, BSN, CCDS
Supervisor, Clinical Documentation Integrity
UWHealth University of Wisconsin Hospital
Office Location: University Crossing, 749 University Row, Suite 200
Mailing Location: 600 Highland Avenue, Mail Code 9920
Madison, WI 53792-9475
608-516-5638
kbenson@uwhealth.org
[cid:image001.png@01D0F6DC.873AF390]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 3:01 PM
To: Benson Kathleen
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Kerry!
Thanks for your response! I agree that it seems expected but am concerned that coding may not agree. In this case would you query just to make sure?
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 12:41 PM
To: Kathryn Good
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Katy-
We are reviewing these cases along with our quality department. When in doubt, we bring the surgeon in to weigh in.
In your case, it sounds almost expected/unavoidable, though the surgeon doesn't use those exact words. My takeaway from lectures on this topic at the ACDIS conference, and the article below, is that it is best to have the MD's state if integral/inherent, necessary and/or unavoidable.
Check out this article from ACS-
http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/
Some highlights-
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the "injury" to a structure is expected, then the surgeon should use language such as:
* "The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed."
* "Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with...."
* "At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers."
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Seekircher, Kerry
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Copyright 2013
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________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 4:01 PM
To: Seekircher, Kerry
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Kerry!
Thanks for your response! I agree that it seems expected but am concerned that coding may not agree. In this case would you query just to make sure?
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 12:41 PM
To: Kathryn Good
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Katy-
We are reviewing these cases along with our quality department. When in doubt, we bring the surgeon in to weigh in.
In your case, it sounds almost expected/unavoidable, though the surgeon doesn't use those exact words. My takeaway from lectures on this topic at the ACDIS conference, and the article below, is that it is best to have the MD's state if integral/inherent, necessary and/or unavoidable.
Check out this article from ACS-
http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/
Some highlights-
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the "injury" to a structure is expected, then the surgeon should use language such as:
* "The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed."
* "Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with...."
* "At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers."
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Seekircher, Kerry
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:28 PM
To: Kathryn Good
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
I would query to make it 100% clear in the medical record.
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 4:01 PM
To: Seekircher, Kerry
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Kerry!
Thanks for your response! I agree that it seems expected but am concerned that coding may not agree. In this case would you query just to make sure?
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 12:41 PM
To: Kathryn Good
Subject: RE:[cdi_talk] APL: Complication vs unavoidable/integral
Hi Katy-
We are reviewing these cases along with our quality department. When in doubt, we bring the surgeon in to weigh in.
In your case, it sounds almost expected/unavoidable, though the surgeon doesn't use those exact words. My takeaway from lectures on this topic at the ACDIS conference, and the article below, is that it is best to have the MD's state if integral/inherent, necessary and/or unavoidable.
Check out this article from ACS-
http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/
Some highlights-
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the "injury" to a structure is expected, then the surgeon should use language such as:
* "The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed."
* "Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with...."
* "At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers."
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 24, 2015 2:16 PM
To: Seekircher, Kerry
Subject: [cdi_talk] APL: Complication vs unavoidable/integral
Another APL question:
We have a complicated patient that went for an ex-lap for lysis of adhesions. Prior to the procedure the physician documented:
"I will plan to take to o.r. tomorrow for ex lap and lysis of adhesions. she understands high risk for enterotomy."
She had the procedure:
"I was very careful in attempting to gain entrance into the abdomen. However, I did enter her small bowel inferiorly. I then made an incision in a more superior position in an attempt to gain entrance to the abdomen in this position; however, with just blunt dissection from my finger, I entered her colon which was paper-thin. At this point, I terminated the procedure as I felt that there was no way that I was going to be able to get entrance into the abdomen and reveal it to get to the point where I could fix these enterotomies. The abdomen was frozen. I approached, scrubbed and went and spoke with the daughters and then came back to the operating room, scrubbed back in and placed a wound VAC over the wound the procedure"
Afterwards the PN states: "Findings: purulent drainage from anterior abdominal wall wound multiple enterotomies with extremely friable tissue essentially frozen abdomen"
It seems like the surgeon new this was likely because of how fragile it was and the expected (poor outcome) occurred. But I am wondering what you would do with this. Do you query for inherent? Should this be tagged as an APL? Or is documentation sufficient to support it not being an APL?
This is a new area for us and I would love input from anyone who actively is working on PSI's.
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: kathryn.good@nahealth.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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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