To Code or Not to Code: That is the Complication
Scenario:
Patient admitted with small bowel obstruction requiring right hemicolectomy with ileocolic anastomosis, Hartman’s procedure with end colostomy and mucus fistula creation, and enterocolic fistula takedown. The patient had extensive lysis of adhesions that require more than 2 hours. The falciform of the liver was severely adhered to the antimesenteric border of the transverse colon as well as the Glisson's capsule and during the dissection it was noted the laceration in segment 4B of the liver that had to be repaired via hepatorrhaphy and falciform plication.
Coding Clinic, 4th Qtr, 2023, clarified that an intraoperative serosal tear with minor repair is not considered a significant part of the surgery, and that documentation must state that the tear is extensive, alters the course of surgery in which would increase operative time, the risk of other complications, and potentially increase the length of stay.
Does the hepatorrhaphy and falciform plication meet the definition of the Coding Clinic clarification in that it was not considered a significant part of the surgery as it did not alter the course of the surgery?
Thank you!