From what I have read, if a tear or laceration of an adjacent organ is unavoidable due to excessive adhesions for example, and is documented as such in the operative report it should be considered intrinsic to the procedure and not coded as a complication. However the coders I work with disagree.   Also "some indication in the documentation that it is a complication" is very vague and open to different interpretations.

I would appreciate input on this subject.  Thank You, Julie


  • I would tend to agree with you.  There is an older thread that touches on this topic:


  • PSI 15- Accidental puncture or laceration during procedure excludes cases "with principal diagnosis denoting technical difficulty (e.g., accidental cut, puncture, perforation, or laceration)"
    The setting presented in which extensive adhesions is documented would be c/w a technically difficult case. I agree that this is not a complication and should not be coded as such.
    In any case, to avoid coding complications when they were not actually present, it might be reasonable to educate the surgeons to document that the injury was unavoidable due to extensive adhesions to avoid confusion. 
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