Health Information Management

News: NQF issues proposed new definition of items retained during surgery

CDI Strategies, December 9, 2010

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The National Quality Forum (NQF) published a draft report updating the NQF-endorsed Serious Reportable Events in Healthcare: A Consensus Report. The new report includes an updated list of serious reportable events (SREs) that includes 25 updated SREs and four new SREs, including the following proposed new definition of end of surgery:

“Surgery ends after all incisions or procedural access routes have been closed in their entirety, device(s) such as probes or instruments have been removed, and, if relevant, final surgical counts confirming accuracy of counts and resolving any discrepancies have concluded and the patient has been taken from the operating/procedure room.”

Robert Gold, MD, CEO of DCBA, Inc., in Atlanta, GA brought the new definition to the attention of the editorial board of AHA Coding Clinic for ICD-9-CM in hopes that it will eventually change the rules for how ICD-9-CM code 998.4, Foreign body accidentally left during a procedure, is reported. Currently, if a sponge, needle, and instrument count at the end of a case leads to re-opening the wound to retrieve an object found on x-ray, a coding specialist may report 998.4, which is considered a complication of surgery.
“Right now, even if a doctor leaves something behind purposely, there’s no way to identify it, whether it’s a surgical instrument purposely left or another foreign body purposely left,” Gold says.
For example, Gold cites a piece of a needle tip lodged in the annulus of the mitral valve, the retrieval of which would cause more damage than leaving it in place, as an item purposely left behind that a coder can currently report with 998.4.
“That [coding rule] must be fixed in order to differentiate it from something accidentally left behind,” he says.
The NQF draft document is open for public comments, which must be submitted no later than 6 p.m., EST, on December 23, 2010. Go to the NQF website for more information

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