Health Information Management

Don’t let problematic coding advice lead you astray

JustCoding News: Inpatient, July 21, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

by Robert S. Gold, MD

When a patient has a life-threatening condition, my training as a surgeon leads me to do whatever is necessary to get the patient healthy. I act, and I act quickly.

The publishing world doesn’t work with this same sense of urgency. For example, the editors who oversee the American Hospital Association’s (AHA) Coding Clinic conduct extensive meetings and deliberate over revisions. Even when industry experts and authorities provide valid support for a particular edit or change, it’s a long and laborious process to ensure that change is eventually printed or even printed at all.

Foreign bodies retained after surgery

Consider Coding Clinic, first quarter 2009, in which one scenario pertains to retrieving a sponge from a patient’s body before he or she leaves the operating room (OR). Coding Clinic refers to the National Quality Forum’s (NQF) definition of “end of surgery” and advises coders to assign 998.4 (foreign body accidentally left during a procedure) despite the fact that the foreign body was not left inside the patient’s body.

Based on the NQF criteria, I can understand why the AHA provided the advice. The association’s position is that the surgeon closed the operative wound. The NQF defines the case as having been concluded. However, as it turns out, the definition is incorrect, and the coding guidance must be revised.

As a surgeon, I know that sponge, instrument, and needle counts are an integral part of an operative procedure. Surgeons and OR teams who perform the counts do not conclude a case until the counts are correct. If they did, they would be making a conscious decision to potentially leave a foreign body inside, and that’s just not likely. In the 2009 Coding Clinic scenario, surgeons removed the sponge while performing the count. Therefore, coders should not report 998.4, as the patient is still in the OR when the object is removed.

The NQF agrees that coders shouldn’t report 998.4 when the foreign body is retrieved without having to return the patient to the OR and without having to reinstitute anesthesia. The American College of Surgeons also agrees with me, as does the Agency for Healthcare Research and Quality. Verna Gibbs, MD, a nationally known leader whose efforts focus on minimizing problems with foreign bodies left inside of patients, is also on board. Each of these renowned and reputable sources agrees that the NQF’s definition of “end of surgery” is inappropriate. I presented the evidence from all of these sources to Coding Clinic only to find out that the publication won’t print a revision until the NQF revises its own definition of “end of surgery.”

Let’s look at a few concerns, including how and when counts occur during a closure. A sponge, instrument, and needle count is started prior to the surgeon beginning closure, whether it’s the abdomen, the chest, or the brain. After the count, closure continues. If the count is correct, the closure proceeds, and the patient is reversed from anesthesia and taken from the OR to a recovery area.

If there is a discrepancy in the count, everything halts, including the closure. A second count is then performed. If the count is accurate, closure continues. If not, an x-ray is performed in the OR to locate the missing object. If the object is located, the wound is reopened and the object is removed. The only exception to this case is when the surgeon makes a conscious decision to leave the object there because there is no need to remove it.

Some closures take 15–20 minutes, and the sponge count is completed long before the wound is closed. Other surgeries require a single-running stitch, and closure is completed well before the sponge count is complete. Regardless, if during the course of a quality-oriented count an object is found and retrieved, it is unanimous that coders should not assign 998.4. However, for now, coders are stuck with either assigning it or disobeying advice. If you ask me, I’d rather disobey the advice because it’s the right thing to do.

SIRS with and without infection

Another example relates to Coding Clinic, first quarter 2010, in which one scenario involves a patient with pancreatitis who also has systemic inflammatory response syndrome (SIRS). In the scenario, the physician insists that this is SIRS without infection. Coding Clinic advises coders to assign 995.93 (or 995.94 if associated with organ failure), as pancreatitis is not an infection. The scenario also addresses how to code cholangitis, diverticulitis, and orchitis, stating that coders should report 995.93 or 995.94, as appropriate, for these conditions.


Although pancreatitis is typically non-infectious (except in cases of mumps pancreatitis or pancreatic abscess), cholangitis and diverticulitis are always infectious. Therefore, 995.93 (SIRS due to non-infectious process without acute organ dysfunction) or 995.94 (SIRS due to non-infectious process with acute organ dysfunction) are never appropriate for SIRS identified in these conditions. In fact, SIRS is inherent in both of these conditions and should not be separately reported. However, Coding Clinic advises coders to report these codes when SIRS is present with all three conditions. That’s incorrect.
I contacted Coding Clinic within days of publication to explain my position on the lack of clinical validity to the advice given. The response was that the editorial advisory board needed to discuss the change, and the group wouldn’t reconvene until fall. I guess for the next six months, coders must do the wrong thing and for the wrong reasons. I’d ignore this misguided advice.

Editor’s note: This article was originally published in the July issue of Briefings on Coding Compliance Strategies. Dr. Gold is CEO of DCBA, Inc., an Atlanta consulting firm that provides clinical documentation improvement programs. Contact him at 770/216-9691 or

Interested in hearing more from this coding expert? Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, will discuss inpatient wound care coding during an upcoming HCPro audio conference, “Inpatient Wound Debridement and RACs: Documentation and Coding Improvement Strategies” on Thursday, August 5. 

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular