How to Code Unavoidable Tears/Lacerations
Hello - looking for some guidance on this.
Patient had an open left partial nephrectomy. Let microdissection of renal artery and vein. Open left renal vein repair. Open left renal artery branch repair. Open repair of peritoneum. Open repair of the liver. The provider documented "This repair was required since this tumor was too close to the hilum, that when we removed it, we had to actually repair two branches. One renal artery and one renal vein branch, deep in the parenchyma."
"The peritoneum was very thin, so we had an unavoidable opening in the peritoneum that had to be repaired with 3-0Vicryl. The same thing happened with liver, all the way in the back."
"We had to repair two branches. One artery and one vein, primarily. Since the kidney was so close to the parenchyma, we also repaired the collecting system and proceeded then to pretty much run also a Monocryl in a 4-point stitch in order to close the parenchyma itself."
The provider has done a great job of documenting that these were unavoidable due to the patient's anatomy/scenario and were only requiring sutures to repair -no further extensive surgery - so how are they coded?? Or do you not code them? It definitely is not a complication.