Surgical Complication??

nursronnam

This is part of a dictation from and OR report.

"In mobilizing the splenic flexure, there was approximately
2 x 2 cm splenic capsule tear. Cautery followed by flow seal and
Surgicel as well as compression were used to control the bleeding.
This was successful by the end of the case"

My question is: Should this be coded as a complication. Some sources it says yes, while others say no. I would just love your feed back on this issue.

Thanks

tiffany_susan

The most important thing to do is ask the surgeon. I sit on our surgical
complication review committee that meets monthly, and I have found it
invaluable! There are times, due to previous surgeries, scar tissue,
etc....... that this is not complication, but expected .................
the surgeon in the patient will know.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

david.smith

I believe the guidance on this would be to query the surgeon in order to determine the significance of the tear. Depending on the other circumstances surrounding the procedure (adhesions??), the tear may be considered insignificant/inherent to the procedure.

See the following Coding Clinics for more discussion:
2007 Q2 p.11-12
2010 Q1 p.11-12
1990 Q3 p.18

fentona@bronsonhg.org

This was a hot topic here last year when our consultant from 3M was on site. Yes, I agree to query is best. But he said if it does not say it is a complication that it should not be coded as a complication. It is entirely physician driven.
Thanks,
Amy