Do you code the fracture
Hello,
Would like some opinions- Patient has Aortic valve disorder - stenosis with regurgitation. comes in for Aortic valve replacement using a 19mm bioprosthetic aortic valve (Inspiris by Edwards) using mini-anterior thoracotomy
Op note states " Sternocostal fractures x 2 - expected with this exposure, 4th rib complete fracture and separation from sternum requiring stabilization Open reduction and fixation of sternocostal fracture using linear plate and screws (Lorenz) x 1
Do you code the fractures or not code the fractures since this was expected (complexity of procedure or patient's anatomy or for some other reason).
Thanks for your insight.
Would like some opinions- Patient has Aortic valve disorder - stenosis with regurgitation. comes in for Aortic valve replacement using a 19mm bioprosthetic aortic valve (Inspiris by Edwards) using mini-anterior thoracotomy
Op note states " Sternocostal fractures x 2 - expected with this exposure, 4th rib complete fracture and separation from sternum requiring stabilization Open reduction and fixation of sternocostal fracture using linear plate and screws (Lorenz) x 1
Do you code the fractures or not code the fractures since this was expected (complexity of procedure or patient's anatomy or for some other reason).
Thanks for your insight.
Comments
I tend to be 'conservative' in regards to coding and CDI, and my opinion is that since this was stated as apparently expected and unavoidable, I would not code the fracture.
On the other hand, the CC below directs that rib fx as a consequence of CPR, when present, ARE coded, but not as a complication.
So, this may speak for coding such fractures? So, if the record was very clear that a fracture is considered integral to this procedure and is expected, perhaps it should not be coded. If this is not clear, then one might argue a fx should be coded.
VOLUME 30 FIRST QUARTER
NUMBER 1 2013, Page 15
Rib Fracture due to Cardiopulmonary Resuscitation (CPR)
Question: What is the diagnosis code assignment for a rib fracture due to cardiopulmonary resuscitation?
Answer: Assign code 807.00, Fracture of rib(s), sternum, larynx, and trachea, rib(s), closed, rib(s), unspecified, and code E879.8, Other procedures without mention of misadventure at the time of procedure, as the cause of abnormal reaction of patient or of later complication, Other specified procedures. Fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not uncommon and a known risk; therefore, this would not be classified as a complication. Although the fracture is not considered a complication, the E-code is assigned to provide information about how the fracture occurred.
A few more thoughts:
"Sounds like" from your note this fracture may have been intentional as part of the approach?..."expected with this exposure". If so, no code at all.
Cloudy topic and others may not share my opinion.
Related thoughts re: "What may be a complication"
The term ‘postoperative’ may suggest a complication – be sure to document fully and to clearly indicate intended or inherent versus accidental occurrences
The term ‘postop’ is ambiguous and confusing; it means only ‘occurring after surgery’ and does not by itself establish a cause & effect relationship
Conditions stated as ‘postoperative’, such as ileus, atelectasis, may be reported as a ‘complication’ unless the record documents as ‘expected consequence’ of surgery
The Arkansas Foundation for Medical Care (AFMC) has specifically advised physicians: “If a patient has a condition that occurred in the post-operative period, but it is not considered a complication of the procedure, the term ‘postop’ should not be used”
Consistent use of terms “inherent,” “integral,’ or intended and explicit documentation when complications occur will ensure outcomes data is properly reported
Not all conditions that occur during or following surgery are classified as complications. There must be more than a routinely expected condition or occurrence; in addition, there must be a cause & effect relationship between the care provided and the condition, and an indication in the documentation that a complication is present
Example: A significant amount of blood loss is usual and expected with joint replacement surgery; hemorrhage would not be considered a complication unless such bleeding is particularly excessive or unexpected
Paul Evans, RHIA, CCDS