ileus
Can anyone tell me when you would code an ileus as postoperative? Its usual for a pt to have an ileus post GI surg but when should it be coded, what time frame should be used to determine ifit is a postoperative ileus 997.4 ? Thanks
Comments
educated our surgeons to simply say ileus instead of post-operative
ileus if it was NOT a complication. That's another instance between
clinical verbiage and coding verbiage/rules not being equitable. The
surgeon is talking about time frame, not necessarily cause/effect.
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Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org
Dr. B - I was made aware of your response to one of our documentation specialist's queries regarding a post-op ileus. (that we were splitting hairs way too finely). I wanted to explain the rationale why we ask this clarification question.
When you document "post-op ileus", the Index to Diseases classifies this to ICD-9 code of 997.4 - Digestive system complications. If the coder went solely by the Index to Diseases, a complication of surgery code would be automatically assigned. However, if your patient is experiencing a "normal" physiologic ileus due to gut dysmotility s/p abdominal surgery and is a benign condition that resolves without intervention, no code should be assigned as this does not meet the definition of a reportable secondary diagnosis. However, when an ileus is prolonged and unexpected and requires additional testing or resources (xrays, NG's, prolonged NPO status) and is a complication of the surgery (as opposed to being due to narcotics or autonomic neuropathy), it needs specified as such in order to reflect the higher severity of illness that these pts represent.
Basically, we want to ensure the correct ICD-9 code is selected by our coders (who are non-clinical personnel) and that the code they assign represents the diagnosis you intended.
So, if your pt has a post-op ileus that is expected given the type of surgery you performed, consider documenting "expected post-op ileus"
If your pt has an ileus after surgery that you suspect is due to narcotics, specify this as "post-op ileus due to narcotics"
If your pt has a post-op ileus that extends beyond the timeframe of what you would normally expect and requires additional resources and testing, consider documenting "prolonged post-op ileus - a complication of surgery."
This will ensure appropriate coding of your pts medical record and keep us in good standing from a compliance standpoint.
LeeAnn Conaway, RN III, CCRN, CCDS
CDS Coordinator
UPMC Altoona
Quality Management
814–889–3313 office
814–502-6772 cell
According to this article, "when a definition of postoperative ileus is stated, the timeframe is not given or is inconsistent between studies."
http://www.uptodate.com/contents/postoperative-ileus
A review from New Zealand states, "There is a lack of an internationally accepted standardised clinical definition for postoperative ileus....Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) “interval
from surgery until passage of flatus/stool AND tolerance of an oral dietâ€; prolonged POI “two or more of nausea/vomiting,
inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after
day 4 postoperatively without prior resolution of POIâ€; recurrent POI “two or more of nausea/vomiting, inability to tolerate
oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of
POI." J Gastrointest Surg (2013) 17:962–972
Other articles I've read basically say the same thing--that there's no established definition, and they're much more recent than the 1990 article you cite.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
I 100% agree with your efforts to educate. My issue is that my region is huge and we have a residency program. It is inevitable that the term “PO ileus’ will be documented on our cases, even on PO Day #1. Hence, in addition to educational efforts, I must create a query for this recurring issue.
Have you built a query? Here is my DRAFT to date.
Ileus Post-op
Query:
On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has ***. Clinical evaluation / treatment includes ***.
The surgical procedure XXX was performed on DATE
Please clarify the clinical significance, acuity, etiology, and severity of the findings noted in the medical record.
You may answer this query by marking the checkbox(es) below or using free text at the ( * ) if appropriate.
Provider Query Response:*
There is no Ileus for this case
Ileus was present before a procedure and is unrelated to procedure
Ileus started after the procedure but is due to a disease
Ileus started after the procedure but is due to a medication
Ileus is due to the procedure and is out of the ordinary, thus should be coded as a complication
Ileus is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis
Other (please specify)*
If ileus is not due to surgery, please provide its nature and/or underlying cause
Ileus – adynamic
Due to gallstone
Duodenal, chronic
Mechanical
Due to cystic fibrosis
Myxedema
Fecal impaction
Due to adhesions
Due to anesthesia
Due to immobility
Mechanical
Other (please specify)*
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Definitions
NSQIP Definition- Prolonged Postoperative Ileus: Patient with an ileus managed with a nasogastric tube and/or the patient is NPO for ≥ postoperative day 3.
Note: The patient must be on strict NPO status (NPO w/ ice chips or sips does not count)
Postoperative Ileus - Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus. (Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [Medline].)
Definitions Below from Stedman’s
Ileus- Mechanical, dynamic, or adynamic obstruction of the intestines; may be accompanied by severe colicky pain, abdominal distention, vomiting, absence of passage of stool, and often fever and dehydration
Adynamic Ileus - obstruction of the bowel due to paralysis of the bowel wall, usually as a result of localized or generalized peritonitis or shock
Dynamic Ileus - intestinal obstruction due to spastic contraction of a segment of the bowel
Gallstone Ileus - obstruction of the small intestine produced by passage of a gallstone from the biliary tract (usually the gallbladder as a result of cholecystitis) into the intestinal tract (usually by means of a fistulous connection between the gallbladder and the small intestine); occurrence and site of obstruction depend on size of the stone, but the usual location is at or near the ileocecal junction
Mechanical Ileus - obstruction of the bowel due to some mechanical cause, e.g., volvulus, gallstone, adhesions
Meconium Ileus - intestinal obstruction in the fetus and newborn following inspissation of meconium and caused by lack of trypsin; associated with cystic fibrosis
OCCLUSIVE Ileus - complete mechanical blocking of the intestinal lumen
Ileus SUBPARTA - obstruction of the large bowel by pressure of the pregnant uterus
Terminal Ileus - obstruction of the lower part of the small bowel
Verminous Ileus - obstruction due to masses of intestinal parasites
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I don't have access to the NSQIP site.
Thanks for ANY help. I just know we are over reporting ileus after surgery.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
The clinical situation is the important thing to factor. When a patient has surgery for an infectious process in the abdomen, an ileus exists per-op (although almost nobody identifies it) or if there is bowel that is lacking oxygenated blood as in mesenteric infarction or strangulated hernia. All of these patients have an ileus going in. And guess what! They will have an ileus coming out. And this, barring significant contaminating events during the surgery or further infarcted bowel, this will last from 3 days to a week depending on the patient. If the doc thinks that the patient's prolonged time without resuming bowel activity is due to the inflammatory or ischemic process, then the complication code is not to be assigned - and maybe the ileus could be identified as starting pre-op if that is indeed an observation. Internal hernias will be seen to have an obstructive ileus pattern on x-ray - and they will have ileus post-op. When the peritoneal cavity is clean going in with an elective case, then there will virtually always be a physiologic ileus that averages three days - again depending on the patient. Patients with diabetic autonomic neuropathy, such as gastroparesis, may have prolonged time before opening up due to the diabetic autonomic dysfunction - again, not a complication code if the link is made. Usually, and I must say it from the perspective of a surgeon, if there is a clean, clean case and no other explanation for prolongation of time to resume bowel function, something may have been missed. There could be a pelvic abscess from inadvertent enterotomy or a wound infection or some other event you can point to. Whatever the case, this represents a complication - maybe even two complications. Rough handling of the bowel will lead to prolonged ileus - over 3 days without other problem identifiable - again, a complication. The most important things to consider are another cause of mechanical or reflex ileus that existed before the incision and linking the ileus to that process (any of the above) or something untoward happened. Put on your clinical hat to review the case before approaching the doc.
Whatcha think?
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
When I see this, I want to issue a query in hopes either the surgeon will indicate it is not proper to code an ileus, and/or some other MD will review the chart and clarify there is no p.o. ileus...this is a 'reverse query'. ACDIS/AHIMA Best Practice...issue a query for a diagnosis rendered, but may be lacking in clinical support.
Ileus Post-op
Query:
On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has post operative ileus. Clinical evaluation / treatment includes ***.
The surgical procedure XXX was performed on DATE
Please clarify the clinical significance, acuity, etiology, and severity of the findings noted in the medical record.
You may answer this query by marking the checkbox(es) below or using free text at the ( * ) if appropriate.
Provider Query Response:*
0 There is no Ileus for this case
0 Ileus was present before a procedure and is unrelated to procedure
0 Ileus started after the procedure but is due to a disease
0 Ileus started after the procedure but is due to a medication
0 Ileus is due to the procedure and is out of the ordinary, thus should be coded as a complication
0 Ileus is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis
0 Other (please specify)*
If ileus is not due to surgery, please provide its nature and/or underlying cause
0 Ileus – adynamic
0 Due to gallstone
0 Duodenal, chronic
0 Mechanical
0 Due to cystic fibrosis
0 Myxedema
0 Fecal impaction
0 Due to adhesions
0 Due to anesthesia
0 Due to immobility
0 Mechanical
0 Other (please specify)*
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Definitions
NSQIP Definition- Prolonged Postoperative Ileus: Patient with an ileus managed with a nasogastric tube and/or the patient is NPO for ≥ postoperative day 3.
Note: The patient must be on strict NPO status (NPO w/ ice chips or sips does not count)
Postoperative Ileus - Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus. (Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [Medline].)
Definitions Below from Stedman’s
Ileus- Mechanical, dynamic, or adynamic obstruction of the intestines; may be accompanied by severe colicky pain, abdominal distention, vomiting, absence of passage of stool, and often fever and dehydration
Adynamic Ileus - obstruction of the bowel due to paralysis of the bowel wall, usually as a result of localized or generalized peritonitis or shock
Dynamic Ileus - intestinal obstruction due to spastic contraction of a segment of the bowel
Gallstone Ileus - obstruction of the small intestine produced by passage of a gallstone from the biliary tract (usually the gallbladder as a result of cholecystitis) into the intestinal tract (usually by means of a fistulous connection between the gallbladder and the small intestine); occurrence and site of obstruction depend on size of the stone, but the usual location is at or near the ileocecal junction
Mechanical Ileus - obstruction of the bowel due to some mechanical cause, e.g., volvulus, gallstone, adhesions
Meconium Ileus - intestinal obstruction in the fetus and newborn following inspissation of meconium and caused by lack of trypsin; associated with cystic fibrosis
OCCLUSIVE Ileus - complete mechanical blocking of the intestinal lumen
Ileus SUBPARTA - obstruction of the large bowel by pressure of the pregnant uterus
Terminal Ileus - obstruction of the lower part of the small bowel
Verminous Ileus - obstruction due to masses of intestinal parasites
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)