Coding Clinic Q1 2022 p 51 intraoperative serosal tears
Hello all.
Our organization fully expected the advice in CC Q2 2021 pg 8 to be reversed on coding complications when the surgeon has documented unavoidable or inherent to the procedure but that did not happen (thank you Laurie Prescott for your article defining the dilemma).
How are organizations giving provider education on what should be documented for a small tear or laceration requiring 1 stich? 3 stiches? 7 stiches?
If I query for the provider's clinical opinion on whether the tear and subsequent repair is clinically significant or not they ask the CDI- what is the definition of clinically significant?
I don't want CDI or coding to be making clinical decisions for the surgeons- how do we handle this? Is every tiny serosal tear a complication?
HELP!!!
Comments
This is a question we have as well!
Clinically Significant: see Official Coding Guidelines:
Code all clinically significant conditions
All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring; or
has implications for future health care needs
Note: The perinatal guidelines listed above are the same as the general coding guidelines for “additional diagnoses,” except for the final point regarding implications for future health care needs. Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs.
Section III. Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring
Documentation of Complications of Care
Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code.