Por William C. Fiala, MA, CCS-P, CPC, RMA e Kristine N. Kraft, DC, RMA
Complication coding is “considered one of the most challenging aspects of coding”, as an article in ICD10monitor once put it.1Reporting complication codes poses certain risks for providers and institutions, ranging from unfavorable credential scores to increased liability and reduced payout. As Vanessa Fuhrmans reports inWall Street Journal, some insurers even refuse to pay "for treatments triggered by some complications that they believe hospitals should prevent".2Coding professionals need to continue to expand their knowledge of pathophysiology and expand lines of communication with providers to ensure that all complication code reports are accurate. This article analyzes a possible complication – postoperative ileus – and the circumstances of its coding.
In medical dictionaries, ileus is often defined as an intestinal obstruction.3,4Dr Edward Livingstone and Dr. Edward Passaro defined it in his 1990 discussion as "a state of inhibited bowel function" in which there is "functional inhibition of propulsive bowel activity".5Physicians further defined postoperative ileus as "uncomplicated ileus that occurs after surgery and resolves spontaneously within two to three days" that is "transient in the small intestine, 24-48 hours in the stomach, and 48-72 hours in the colon". stops.6Other authors noted a "general consensus that some degree of postoperative ileus is a normal and obligatory physiological response to abdominal surgery" and a "generally benign condition that resolves without serious sequelae".7The expected result of the operation can have a prophylactic address:
Nasogastric suction to relieve intestinal obstruction was introduced in 1884. Nasogastric intubation had a tremendous impact... and has become the standard after abdominal procedures where ileus is a problem. It was and is so common that it is still routinely used as a prophylactic.8
Coding professionals should note that postoperative ileus, at least in the short term, can be a normal and expected result of surgery for which prophylactic measures may be routinely ordered.
With a reasonable definition of postoperative ileus, it becomes easier to understand what constitutes a complication. In their 2004 proposal for a classification of surgical complications, Drs. Dindo, Demartines and Clavien defined surgical complications as "any deviation from normal postoperative care".9Health information management experts similarly define a complication as a condition "that is likely to increase the intensity of services needed to provide care to the patient" and "a condition that occurs during the hospital stay and that alters the course of the patient's illness or necessary medical care".10,11Key elements of these definitions include 'deviation from normal', 'increase in intensity' and 'change of course'.
The ICD-10-CM coding guidelines add another component to the definition of a complication: a link between the discrepancy, increased intensity or changed treatment plan and the previous treatment provided - in this case, surgery. According to the guidelines:
Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless the classification indicates otherwise. The policy extends to all treatment complications, regardless of which chapter the code falls under. It is important to note that not all conditions that occur during or after medical or surgical treatment are classified as complications. There must be a cause and effect relationship between the care provided and the condition, and there must be an indication in the documentation that the complication is a complication.12
A surgical complication is a circumstance in which the patient's treatment plan is changed beyond normal post-operative care and for which the practitioner documents a clear association between the need for the change and the previous procedure.
Armed with definitions of postoperative ileus and surgical complication, how would a programmer report the fact when the vendor documents a "postoperative ileus"?
As of 2012, reporting the condition in the ICD-9-CM seems straightforward enough; In 2012, a new code - 997.40 - was introduced along with subterms or main modifying entries in the alphabetical index under the main term 'ileus', reading 'after gastrointestinal surgery' and 'postoperative', referencing 997.49. Category code 997 is identified as “Complications affecting specific body systems, not otherwise classified”. It seems that the standard for a postoperative ileus was that the condition was a complication, whether or not it lasted less than three days, it was a "normal obligate physiological response" and not a change in normal postoperative care or treatment plan. , and was not specifically identified by the provider as being causally related to the procedure. Similarly, under the main term ileus, the ICD-10-CM alphabetical index has a noun subterm or modifier “postoperative” and refers to code K91.89 with a description of “other postprocedural complications and disorders of the digestive system” and a note “use additional code”. Fortunately, the ICD-10-CM guidelines still contain a very critical instruction: "Ask the physician for clarification if the complication is not clearly documented."13
“Postoperative ileus” documentation provides an excellent time to improve clinical documentation and an opportunity for collaboration between experts and coding providers. Programmers should not assume that the words "postoperative ileus" always refer to a complication defined above, and questions should be asked to clarify documentation. One coding expert reports that vendors are beginning to document "expected ileus ileus," documentation consistent with the idea that ileus is like Dr. Kalff, Wehner, and Litkouhi propose "a normal, obligatory physiological response" that requires no additional resources beyond routine postoperative care and prophylaxis, and documentation that provides some clarity for programmers.14Coding professionals should work with providers in their practice or facility to create clear and consistent documentation so that the circumstance of early postoperative ileus - the normal 2-3 day event that does not require additional resources - is clear and easily understood. distinguished from a complication of surgery—a prolonged postoperative ileus requiring a deviation from normal postoperative care—allowing the encounter to be coded quickly and correctly.
Comments
- CID10 Monitor. "Postoperative complications: it's complicated." March 25, 2016.www.icd10monitor.com/postoperative-complications-it-s-complicated.
- Fuhrmans, Vanessa. "Insurers no longer pay for error-related care services."Wall Street Journal🇧🇷 January 15, 2008.www.wsj.com/articles/SB120035439914089727.
- Stedman's Concise Medical Dictionary for the Health Professions, Terceira Edição. Baltimore, MD: Williams & Wilkins, 1997.
- Tabers Cyclopedic Medical Dictionary: 20. Auflage.Philadelphia, PA: F.A. Davis, 2005.
- Livingston, Edward and Edward Passaro. "Postoperative ileus".Digestive Diseases and Sciences35, no. 1 (January 1990): 121-132.
- Ibidem, page
- Kalff, Jörg C. et al., "Postoperative ileus". Updated. July 17, 2017.www.uptodate.com/contents/postoperative-ileus.
- Livingston, Edward and Edward Passaro. "Postoperative ileus". page 126.
- Dindo, Daniel, Nicolas Demartines and Pierre-Alain Clavien. "Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6,336 Patients and Research Results."Annals of Surgery240, No. 2 (August 2004): 206.
- Gregg Fahrenholz, Cheryl e Ruthann Russo, eds.Documentation for health records. Chicago, IL: AHIMA, 2013: 415.
- Huffmann, Edna.Health Information Management, 10th Edition, Revised by AHIMA. Berwyn, IL: Physician's Record Company, 1994: 234.
- Centers for Medicare and Medicaid Services. Official ICD-10-CM coding and reporting guidelines.www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf.
- ibid.
- HCPro. "Questions and Answers: Solving the Problems of Post-Operative Ileal Coding Through Documentation."CDI Strategies🇧🇷 March 31, 2011.www.hcpro.com/print/HIM-264322-5707/QA-Recoding-coding-postoperative-ileus-worries-with-documentation.
William C. Fiala (wcfiala@uakron.edu) is Professor of Practice, Allied Health Technology, at the University of Akron. Kristine N. Kraft (knk@uakron.edu) is Director of Medical Assistive Technology and Acting Director of the School of Allied Health Technology at Akron University.
citation of the article:
Fiala, William C. "Complicated Coding: Postoperative Ileus." Journal of AHIMA 90, no. 4 (April 2019): 44-45.
FAQs
How do you code postoperative ileus? ›
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. K91. 89 (Other postprocedural complications and disorders of digestive system) and K56.
Is post op ileus a complication? ›Postoperative ileus is a prolonged absence of bowel function after surgical procedures, usually abdominal surgery. It is a common postoperative complication with unclear etiology and pathophysiology. It is a benign condition that usually resolves with minimal intervention.
What is the ICD-10 code for complication ileus? ›ICD-10 code K56. 7 for Ileus, unspecified is a medical classification as listed by WHO under the range - Diseases of the digestive system .
Is postoperative ileus the same as paralytic ileus? ›Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus, paralytic ileus, or functional ileus. Frequently, ileus occurs after major abdominal operations, but it may also occur after retroperitoneal and extra-abdominal surgery, as well as general anesthesia alone.
Is postoperative ileus and obstruction? ›A post-operative ileus is simply a delay in the return of normal bowel function. As a result, the symptoms of post-operative ileus may be the same as those of a mechanical obstruction.
What is the ICD-10 for acute postoperative ileus? ›K56. 7 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM K56. 7 became effective on October 1, 2022.
What is the differential diagnosis for postoperative ileus? ›The common differentials for ileus are pseudo-obstruction, also referred to as Ogilvie syndrome, and mechanical bowel obstruction.
What is the ICD 9 for postoperative ileus? ›ICD-9 code 560.1 for Paralytic ileus is a medical classification as listed by WHO under the range -OTHER DISEASES OF INTESTINES AND PERITONEUM (560-569).
What are two types of ileus? ›Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus.
Is an ileus considered an obstruction? ›Ileus defined as nonmechanical obstruction of bowel usually secondary to inhibition of peristalsis. Small bowel obstruction defined as mechanical obstruction of small bowel due to adhesions, mass, volvulus or other internal or external compression.
What is the difference between an ileus and a bowel obstruction? ›
Ileus, also known as paralytic ileus or functional ileus, occurs when there is a non-mechanical decrease or stoppage of the flow of intestinal contents. [1][2] Bowel obstruction is a mechanical blockage of intestinal contents by a mass, adhesion, hernia, or some other physical blockage.
What is the difference between ileus and volvulus? ›In paralytic ileus there is no bowel movement and no flatus. In sigmoid volvulus the picture is rather like large bowel obstruction with pain, constipation, late vomiting and a very marked degree of abdominal distension.
What is a postoperative ileus? ›Postoperative paralytic ileus refers to obstipation and intolerance of oral intake due to nonmechanical factors that disrupt the normal coordinated propulsive motor activity of the gastrointestinal tract following abdominal or nonabdominal surgery [1-3].
How do you treat postoperative ileus after bowel surgery? ›Nonsteroidal anti-inflammatory drug therapy may improve postoperative ileus by allowing the clinician to reduce the amount of opioid given by 20% to 30%. An additional benefit on bowel motility may be derived from the anti-inflammatory properties of nonsteroidal anti-inflammatory drugs.
What is the difference between Ogilvie's syndrome and paralytic ileus? ›Ogilvie's syndrome, also known as 'paralytic ileus of the colon', is characterised by pseudo-obstruction of the large intestine in the absence of any mechanical obstructing component; and presents as a massively distended abdomen. If left untreated, it may lead to bowel perforation or ischemia.
What causes an ileus after surgery? ›Causes of an ileus
Surgery - Especially abdominal surgery, for any reason; surgery is the most common cause of ileus. This is due to manipulation of the intestines and exposure to the open air. This causes the intestines to go to sleep for up to several days after surgery.
Ileus is a temporary lack of the normal muscle contractions of the intestines. Abdominal surgery and drugs that interfere with the intestine's movements are a common cause. Bloating, vomiting, constipation, cramps, and loss of appetite occur.
What is the cause of postoperative ileus? ›The pathophysiologic factors that cause postoperative ileus can be endogenous (neurohumoral response) or exogenous (anesthesia, opioids). The contribution of endogenous factors depends on the level of pain and the degree of abdominal manipulation.
Is ileus acute or chronic? ›If it's a temporary condition, it's referred to as an ileus. It's called a pseudo-obstruction if it becomes chronic, or long-term. Causes for an ileus include: abdominal or pelvic surgery.
What is the ICD-10 code for post op complication? ›ICD-10 Code for Complication of surgical and medical care, unspecified, initial encounter- T88.
Do you give bowel regimen for ileus? ›
All patients receiving narcotics for pain control should be on a bowel regimen, which should be initiated as soon as possible. An effective bowel regimen should include a stimulant laxative and a stool softener. These agents may include senna, bisacodyl, and docusate sodium.
What is the difference between paralytic ileus and pseudo-obstruction? ›However, pseudo- obstruction is limited solely to the colon, while on the other hand, paralytic ileus involves both the colon and the small bowel. Classic pseudo-obstruction typically involves the right colon and usually appears in trauma patients, or elderly bedridden patients with severe extra- intestinal illness.
How long is post op ileus? ›Following abdominal surgery, a period of "physiologic" ileus is expected to last for 0 to 24 hours in the small intestine, 24 to 48 hours in the stomach, and 48 to 72 hours in the colon.
What is diagnosis code Z93 3? ›ICD-10 code Z93. 3 for Colostomy status is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
What is protracted ileus? ›Postoperative ileus (POI) is a transient inhibition of gastrointestinal (GI) motility that involves the entire GI tract (1). Prolonged POI is characterized by abdominal distention, nausea, vomiting and delayed passage of flatus and stool.
Is ileus the same as gut stasis? ›Ileus or gut stasis is the term used to describe a condition where part of or all of the gastrointestinal tract ceases to move. It is very common in rabbits and guinea-pigs, both as a primary and a secondary condition.
What is the diagnostic criteria for ileus? ›Diagnosis begins with an assessment of the individual's medical history. The severity of signs and symptoms often depends on the presence of intestinal obstruction and may include abdominal pain, bloating, loss of appetite, feeling of fullness, nausea, vomiting, and inability to pass gas or stool.
What are the complications of ileus? ›Ileus Complications
Perforation or blow-out of the intestinal wall. Tissue death (necrosis) Infection of the abdominal cavity (peritonitis)
Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal obstruction in infants and children. Causes of paralytic ileus may include: Bacteria or viruses that cause intestinal infections (gastroenteritis)
What are the symptoms of postoperative ileus? ›Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation.
What is the best treatment for a paralytic ileus? ›
If paralytic ileus doesn't improve on its own, your doctor may prescribe medication that causes muscle contractions, which can help move food and fluids through your intestines. If paralytic ileus is caused by an illness or medication, the doctor will treat the underlying illness or stop the medication.
What bowel sounds are heard with paralytic ileus? ›Clinical features of paralytic ileus
Bowel sounds are absent, flatus is not passed, and there is consequent gastric stasis that could lead to hiccups, discomfort, and effortless vomiting, unless gastric aspiration has been carried out. The abdomen is distended and tympanic.
Ogilvie syndrome is virtually indistinguishable from mechanical obstruction based solely on signs and symptoms. X-ray examination of the colon will be performed to rule out mechanical obstruction. Plain abdominal films (radiographs) can reveal an abnormally expanded (dilated) colon.
What is Ogilvie's syndrome differential diagnosis? ›Differential Diagnosis
Volvulus (cecal, sigmoid) Mesenteric ischemia. Toxic megacolon. Incarcerated hernia.
Postoperative paralytic ileus refers to obstipation and intolerance of oral intake due to nonmechanical factors that disrupt the normal coordinated propulsive motor activity of the gastrointestinal tract following abdominal or nonabdominal surgery [1-3].
Is an ileus the same as a bowel obstruction? ›Ileus and intestinal obstruction have similarities. However, ileus results from muscle or nerve problems that stop peristalsis, while an obstruction is a physical blockage in the digestive tract. However, a type of ileus known as paralytic ileus can cause a physical block due to a food buildup in the intestines.
Does ileus mean obstruction? ›Ileus defined as nonmechanical obstruction of bowel usually secondary to inhibition of peristalsis. Small bowel obstruction defined as mechanical obstruction of small bowel due to adhesions, mass, volvulus or other internal or external compression.
What causes ileus after abdominal surgery? ›Surgery - Especially abdominal surgery, for any reason; surgery is the most common cause of ileus. This is due to manipulation of the intestines and exposure to the open air. This causes the intestines to go to sleep for up to several days after surgery.
What is the bowel regimen for ileus? ›An effective bowel regimen should include a stimulant laxative and a stool softener. These agents may include senna, bisacodyl, and docusate sodium.
Do you have bowel movements with an ileus? ›Signals from nerves tell the muscles when to contract. With ileus, this movement slows down or stops completely. As a result, waste can't move through the bowels and out of the body. This can cause belly (abdominal) pain and other symptoms.
Can you poop with paralytic ileus? ›
Symptoms of paralytic ileus mainly affect the digestive tract. One of the main symptoms is the inability to pass stool or gas.
Can you give laxatives in ileus? ›Patients with post-operative ileus, opioid-induced constipation, or a soft stool will benefit from a stimulant laxative, such as senna or picosulphate.
Can you give MiraLAX with an ileus? ›You should not use MiraLAX if you have a bowel obstruction or intestinal blockage. MiraLAX should produce a bowel movement within 1 to 3 days of using the medication.