Does the recent Coding Clinic advice regarding accidental puncture and laceration contradict Official Coding Guidelines for coding Complications of Care? The short answer is No. Here’s why.
In Coding Clinic 2021 Second Quarter, the following scenario was presented: “During a laparoscopic salpingo-oophorectomy, the surgeon noted an incarcerated loop of small bowel adherent to a ventral hernia sac. After take down, the bowel was discolored with multiple serosal tears. The incision was then extended, the loop of bowel was brought out through the incision and the segment with the serosal injury was excised. It seems that serosal tears requiring excision would be clinically significant. However, in this case, the provider documented the injury was inherent to the nature of the procedure. On query, he stated the serosal tear was ‘Unavoidable during extensive lysis of adhesions, not intraoperative complication.’ Would any bowel injury requiring excision be considered clinically significant and reportable? How is the serosal injury and repair by excising the small intestine coded?
In response, Coding Clinic answered, “Assign code K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure, for the serosal injury of the small intestine. Although after query the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery.”
This may at first seem contrary to the idea that physician documentation governs code assignment of complications of care; however starting with the 2017 Official Coding Guidelines, Section I.B.16 for Documentation of Complications of Care was modified to read (modification in bold):
“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 an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.”
This phrase “unless otherwise instructed by the classification” was added one year after ICD-10 was implemented in FY2016. This instruction was added to reflect the significant refinement and reorganization of the complication of care codes within ICD-10.
In many situations, complication of care codes are now assigned simply because they occur intraoperatively or postoperatively, and therefore do not require a cause and effect relationship or specific provider documentation that a condition is a “complication.”
In this case, the serosal injury occurring during the procedure is assigned to code K91.71, which specifies “accidental puncture or laceration during a procedure.” Therefore, the Tabular entry governs code assignment.
The serosal injury was clearly documented and was clinically significant particularly since an additional surgical procedure was performed to treat the injury. A query would not be required since the documentation was clear and not conflicting or confusing – even though the surgeon documented it was unavoidable due to extensive lysis of adhesions.
Keep in mind that although conditions classified as complications of care are typically unexpected or unusual outcomes by the care rendered, the term “complication” as used in ICD-10 does not necessarily imply that improper or inadequate care was provided or it was a “surgical misadventure.” And many times it isn’t. Particularly with surgeries, there is always a risk of complications which do occur.
What’s important is for these to be tracked so we have good data to improve the quality and outcomes for our patients. If we’re not coding these conditions when they occur, how can we improve the care we’re providing?
In summary, the ICD-10-CM codes for complications of care, the 2017 Official Coding Guidelines change, and Coding Clinic instruct us to code accidental punctures and lacerations that occur during a surgical procedure that are clinically significant. It is not necessary to query providers for a cause and effect relationship or whether it complicated the procedure. An accidental puncture and laceration code should be assigned unless the documentation is unclear or the condition does not meet the definition of an additional diagnosis.
For more information about Complications of Care, see the CDI Pocket Guide by Pinson & Tang.
(c) 2021 Pinson & Tang
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