not clinically significant

katysuegood@gmail.comkatysuegood@gmail.com
in Clinical & Coding

Hi all,

I have a case I could use a hand with. We have a patient with LLL cancer who presented for a scheduled thoracotomy, lobectomy, with lymph node dissection.

A couple days after surgery there is mention of pain at incision site and 'broken rib from surgery'. This is repeated on the following day though not mentioned in the OP note of later progress notes and DCS. The CDI queried as to whether this was a complication or integral to the procedure and the provider responded that it was 'not clinically significant' as fx frequently occurs with thoracotomy and states that the pain was multifactorial from thoracotomy and rib fracture.


This currently popped as a Hospital acquired injury.


Based on the documentation would you code the fracture or not?


thanks!


Katy


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