I just want to be fair to our surgeons. To view all forums, post or create a new thread, you must be an. Ie: does it meet criteria for secondary dx? Jan 15, 2019 When it comes to coding and documentation, finding your own rhythm can lead to positive results. In most cases the manifestation codes will have in the code title, 'in diseases classified elsewhere. Postoperative Shock Per coding guidelines, shock is classified as a complication when it occurs in the postoperative period. If all physicians and coders coded post-op ileus Katy: Nicely stated and all true - which would make me feel even worse were I to blindly follow the Index and assign the code in the manner directed. .
If it is expected is it 'integral' to the procedure? The stay was prolonged due to respiratory issues. Yes, I wasn't referring to your specific case, just in general since this is just an area that I find interesting and especially problematic. I think this should make it inherent to the procedure and they said it was expected due to the massive paraesophageal hernia present preoperatively. I have a real dislike for the way Coding Clinic presented this clinical issue as such advice simply can make the coding profession 'seem misinformed'. This is generally true but in this specific case the coding clinic right or wrong has said this is not needed.
To do so is to unfairly 'ding' a surgeon with a 'complication. Why is a complication code inappropriate in this instance? Next, if a patient develops atrial fibrillation post-operatively, what was the outcome? Its one of those things where if we want to code to the highest specificity we will end up with the complication code because the only way to code it as post-operative. Postoperative Atelectasis Postoperative atelectasis occurs to some degree in many patients undergoing upper abdominal or thoracic surgery, but can occur in any patient who receives general anesthesia. Then again, that would also mean that our expected acute blood loss anemia should likely not be coded on most of our cardiothoracic surgery patients. A bronchoscopy was performed which showed mucus plugs that were removed. Would it be appropriate to assign code 997. If the documentation in the record clearly documents that the ileus is a postoperative complication not just a timeframe for occurrence then two codes are required to fully describe the condition.
Ileus does not always involve intestinal obstruction and may or may not be a true postoperative complication. Billable Code Billable codes are sufficient justification for admission to an acute care hospital when used a principal diagnosis. So, when is postoperative atelectasis a complication? Therefore documentation of a postoperative condition does not necessarily indicate a link between the condition and the surgery, according to Audrey G. Pulses are rapid and weak, and there is decreased urine output. An Excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. By using our Services, you agree that www.
For some of us, we end up falling short of those expectations. Physical exam reveals course lung sounds and heart rate of 100. I thought the relation ship per coding guidelines had to be stated by the provider and if there was a question to query. Check out our tips and tricks for a healthy 2019! If not and it only happens occasionally to patient undergoing this procedure then is it a complication? As for this case, I think it can be seen both ways. Although ileus originally referred to any lack of digestive propulsion, including bowel obstruction, up-to-date medical usage restricts its meaning to those disruptions caused by the failure of peristalsis, rather than by mechanical obstruction.
The physician is documenting postoperative atelectasis as the diagnosis. If so, then post-operative atrial fibrillation is not a complication of surgery and was present on admission. If the physician clearly documents or confirms that the ileus is not a surgical complication, but just occurred in the postoperative period, then only K56. We respond to notices of alleged copyright infringement and terminate accounts of repeat infringers according to the process set out in the U. There are numerous complications that can occur in the post-operative setting. New codes have been added to this category K91. In these instances, the provider should be queried for clarification that the post-operative atrial fibrillation was, in fact, a complication.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. It is an incomplete expansion of the lung segments that may result in partial or complete collapse of the lung. OtisOnOtisDrive When it comes to coding and documentation, finding your own rhythm can lead to positive results. I don't gain a thing here. Post-Operative Paralytic Ileus This issue is probably one of the most common conditions seen following abdominal surgery — but is it a complication? Post-Operative Atrial Fibrillation Determining whether or not to view post-operative atrial fibrillation as a complication has several defining factors.
There must be a cause-and-effect relationship between the care provided and the condition, and an indication that it is a complication. Paralytic ileus occurs in all patients who have major bowel surgery, he says, and they all get treated the same way. A 'billable code' is detailed enough to be used to specify a medical diagnosis. I think one of the problems is that they chose a 997 code when they added it opposed to the?? Physicians are hesitant to document post-operative complications, as they negatively affect their quality scores on sites like Healthgrades. On the other hand, if the post-operative atrial fibrillation required treatment, either with medications or defibrillation, this condition should be considered a complication. Echocardiogram and chest X-ray confirm heart failure. The patient is ordered albuterol nebulizer treatment every 4 hours and prn and is encouraged to use incentive spirometer.
The surgeon wrote it on his own. Search Engine Optimisation provided by - Copyright © 2019 DragonByte Technologies Ltd. The physician has to specifically document that the post-operative atrial fibrillation is a complication of the procedure. It is usually an incidental finding on chest x-rays and resolves spontaneously without treatment. First, does the patient have a history of atrial fibrillation that is currently being treated? I10 — Essential Primary Hypertension; 2. Those facilities that are open to ethically reporting falls will appear 'worse' than those who simply do not report, etc. There are coding clinics that guide us for complications to not assume a link.