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
Jeanne McCorkle BSN, RN, CCDS
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.
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
The complicated process of reporting complications
Q&A: Unavoidable complications
Q&A: Unavoidable complications
Query: Postoperative complication clarification
Query: Post operative complications
Query: Surgical complications
Guidelines clarify complications of care
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
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