question regarding documentation and possibly code assignment

arsusott@msn.comarsusott@msn.com
in CDI Talk Archive
Patient was taken to surgery for ruptured appendicitis. Appendectomy was reported to have been completed. Path result later shows that it was in fact the fallopian tube and so patient was subsequently taken back to the OR and had the appendicitis removed (path confirmed) 3 days later.



Would we code appendectomy on the first encounter since the OP report only supports that, or code salpingectomy based on the path as well as progress notes by the 2nd surgeon? Do we have the 1st surgeon go back and amend the OP report even though he was confident that it was the appendix?”



Thanks!!

Angela Susott, CCS, CPC, CCDS
Clinical Documentation Improvement

Comments

  • Unknown
    edited May 2016
    This is a great quandary.   Coding and billing guidelines will probably drive this.  You can't bill insurance for 2 appendectomy's.  Thus, the original surgeon should do an addendum to the OR report to reflect the excision of the correct body part.  I am interested to hear what others have to say.
    Adrienne

    Adrienne Gmeiner RN, CCS
    Clinical Documentation Improvement
    Lawrence General Hospital

    Telephone # 978.683.4000  X 2261
    email: adrienne.b.gmeiner@lawrencegeneral.org
     

  • kari.eskenskari.eskens
    edited May 2016
    I agree with Adrienne. Also, if the first procedure was done as an outpatient surgical (ASC, same day surgery.... whatever your facility calls it) and the procedure will be reported with a CPT code, you will need to use either modifier -PA or -PC.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager


  • sbeattysbeatty
    edited May 2016
    I agree. This can only be coded based on the documentation of the
    surgeon. He should be queried to correct the conflict in documentation
    regarding the first surgery. The discrepancy is between the op note's
    stated procedure and the results of the pathology order for that
    operative specimen; it doesn't support his statement of procedure.
    Depending on how that goes, you'll know (hopefully) what to do about the
    second surgery. Likely the surgeon has some internal conflict about how
    to fix the documentation. Is the first surgery a complication of the
    attempted appendectomy? Does he redo the entire first operative note?
    I'd utilize the director of HI to help you with this one! Let us know
    how it turns out.



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • digardskdigardsk
    edited May 2016
    Is this case undergoing a root cause analysis (vs straight peer review)?
    If so, there might be a conclusion from there on how the final
    documentation will stand.


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    If I am reading this correctly - the wrong internal organ was removed during the initial surgery. If that is the case - I would refer this case to quality and dept chair for followup. This is beyond the scope of CDI at my facility.



  • jolene.filejolene.file
    I would agree that the wrong surgery is an issue for the Quality Dept.
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