Post op complications

We are experiencing problems with physicians documenting a post op condition , which is coded as a post op complication.  When they receive their Crimson quality data and the charts are reviewed, they are telling us that the condition was not a complication of the procedure but the condition occurred in the post op time period and that is why they documented as a post op condition.  How are people education their physicians on documenting conditions that occur after surgery?  If they document "post procedural xxxx", would the condition still be coded as a post op complication?

Comments

  • It can be tricky.  "Post-procedural" really only identifies the timeline, not the cause.  I would query to capture "due to" before taking as a complication.

    Jeanne McCorkle BSN, RN, CCDS
  • To further expand on the above question, when a thoracotomy is performed, there is typically a post op pneumothorax with an air leak, how should the surgeon document that so that it is not listed as a complication?
  • To further expand on the above question, when a thoracotomy is performed, there is typically a post op pneumothorax with an air leak, how should the surgeon document that so that it is not listed as a complication?

    When something is routinely expected after a procedure, the MD should make that clear in their documentation. For example, a few years back we had issues with "post operative" ileus being documented on every post op patient. They are now documenting "awaiting return of bowel function" or "expected ileus" if they feel they need to document something.
  • Thanks, that makes sense, however the surgeon is adverse to using "expected pneumothorax with air leak" or "inherent to the procedure" so we are a little stuck.  Certainly folks out there who do thoracotomies at their facilities must run into this weekly as well.  I am curious how others deal with a condition caused by surgery that ends up coded as a complication?
  • You really need the surgeon to address the issue by stating if this an expected event versus a 'complication'. 

    Query:

    On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has CURRENT DIAGNOSIS and is status post SURGICAL PROCEDURE.

     

    Based on your medical judgment and review of the clinical indicators, please clarify the relationship between the DIAGNOSIS and the SURGICAL PROCEDURE.

    You may answer this Query by marking the checkbox(es) below or using free text at the ( * ) if appropriate. Provider Query Response:*

    Incidental occurrence inherent to the surgical procedure

    This should be considered a complication of the procedure

    Unable to determine

    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.

    Paul Evans, RHIA

  • Complex topic.  If you use the search option on the webtise, you will find many excellent articles with background and advice.


    Search Results

    ... p. 5, instructs coders to notrepresent these conditions as complications unless they are more than a routinely expected condition or ... medical record, coders may be forced to code conditions as complications. This doesn’t reflect well on the surgeon or hospital.   ...
    ... the procedure, so would the same hold true for unavoidable complications? A: Since the provider has described it as being ... the procedure, so would the same hold true for unavoidable complications? For example, the provider removed a malfunctioning pacemaker ...
    ... complication happened, and that it was unavoidable. Are any complications that the physician says are unavoidable to be considered inherent ... complication happened, and that it was unavoidable. Are any complications that the physician says are unavoidable to be considered inherent ...
    ... 2012 HCPro Inc., audio conference “Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding ... 2012 HCPro Inc., audio conference “Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding ...
  • QUERY: Request for Documentation Clarification - Bowel Function

     

     

     

    The documentation in the ________________section of the medical record on__________ (insert date) is as follows:

     

     

    PHYSICIAN/PA/NP Responses may include:

     

     


    There is no clinically significant bowel disorder present

     

    Ileus is present and was either monitored/evaluated, treated, extended the length of stay, or lead to increased nursing care, but is expected and is being managed and is not a complication

     

    Ileus is present and related to the procedure, and should be considered a complication as it is unexpected or prolonged beyond the expected period in accordance with the NSQIP Definition.


    Other: (Please Specify)



    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

     

    Mechanical Ileus - obstruction of the bowel due to some mechanical cause, e.g., volvulus, gallstone, adhesions

     

     

     


  • Attached is a 'dated', but speaks to some of the issues and principles re:  complication reporting.


    Paul Evans, RHIA, CCDS

  • Thank you, Paul, for these outstanding resources. Very helpful!


  • It is important to always check the exclusion criteria. PSI 06 Iatrogenic pneumothorax excludes thoracic surgery. From AHRQ (https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V60-ICD09/TechSpecs/PSI_06_Iatrogenic_Pneumothorax_Rate.pdf) : Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.
  • In our facility, the coding of complications was mostly due to coding error and assumption.  There are very specific requirements to even code a complication --there has to be a cause and effect, the MD must indicate it is a complication, etc.   Postoperative _________ (you fill in) should never be coded as a complication without additional documentation.  We were able to drastically decrease our complication rate by really hunkering down and understanding the coding rules surrounding complications, querying when necessary,  the meaning of inherent and unavoidable, and coder/MD education.  I found that most coders were completely unaware of complication documentation requirements.  If they are resistant, involve your compliance department for backup. 
  • I can't imagine a truly informed and educated coding professional would be completely unaware of the complication documentation requirements.  I know these were drilled into me during the two semesters of coding courses I completed at the University, required to become an RHIA.  I work in California, and I have never encountered a qualified coding professional working on the acute side that did know and apply these rules.

     However, you may be unfortunate in that such is the case at your place of employment.  When you say 'most', I hope you mean to say 'most' you have incidentally encountered. 

    Paul Evans, RHIA, CCS, CCS-P, CCDS

  • I find the different impacting programs confusing. I get the exclusion of CT surgery in PSI 06( iatrogenic pneumothorax) but what about  HAC 14 ( which is for for Pneumothorax due to Central line)- most CT surgeries have a central line inserted and could have a postoperative pneumothorax, which is excluded for PSI 06, what would prevent it for being picked up as HAC 14? Thanks,

    Ann


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