Lysis of Adhesions

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in CDI Talk Archive
Our surgeon is concerned that a chart failed chemical VTE prophylaxis on an open hernia operation because lysis of adhesions was coded as the principal procedure based only on the OR dictation which listed lysis of adhesions as one of the postop diagnoses and also included 'thickened adhesions' in the body of the report. Since surgeons stand to fail this measure, should they have input whether lysis of adhesions should be coded?

Comments

  • nursronnamnursronnam
    When you put the simple diagnosis of hernia and adhesions with the surgical repair of hernia w/lysis of adhesions into the encoder, that is shown as the DRG. Without the full chart it is difficult to determine any other DRG assignment. When this first happened to me I was just as confused...
  • sbeattysbeatty
    edited May 2016
    I think it should be queried for "extensive" lysis. Often adhesiolysis
    is part of the procedure and doesn't add any time to the case, or
    increased risk to the patient. It's the cases that take longer than
    usual or that are described as tedious lyses that need to be clarified
    whether an expected part of the principal procedure or a separate
    procedure. If you call your OR scheduling department, they can tell you
    what length of time they expect for different types of surgeries. Then
    look at the start and stop times, as well as the surgeon's description
    of the adhesiolysis to determine if querying is needed.

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