Clinically Speaking: Accidental puncture laceration

Association of Clinical Documentation Improvement Specialists, November 1, 2015

One of the biggest documentation problem areas pertaining to patient safety indicators (PSI), particularly related to PSI 90, stems from accidental puncture and laceration (APL), says Katy Good, RN, BSN, CCDS, CCS, clinical documentation program coordinator at Flagstaff Medical Center in Arizona, which recently implemented a new comprehensive PSI review process. When Good audited a collection of cases from the previous year, she found a number of APL-related issues, including:

  • Lack of queries from CDI for clarification
  • Lack of physician documentation
  • Lack of proper code assignment for every puncture and laceration as a complication

CDI specialists need to decide whether to query when the physician doesn’t state that the laceration is a complication; what constitutes a complication; what terminology should be used when documenting a laceration that is a complication; and how to effectively educate both coders and physicians.

“The biggest challenges for us so far is what is and what is not a complication, and what doesn’t need to be coded versus what does,” says Good.

The first step is creating a review process. Good’s team—which includes six CDI specialists and a manager—try to catch everything concurrently. Both coders and CDI have their own set of PSI-related duties: CDI should be tackling any potential documentation issues related to PSIs, such as whether the present-on-admission status is unclear, or whether a complication exists. As coders work through the record, when they come across a potential PSI, they put the chart on hold and send it to Good, who then reviews the record within 24 to 48 hours.

“Usually my response is ‘it’s fine,’ but sometimes there may be more of a discussion and a learning opportunity,” says Good.

Every Tuesday and Friday, the CDI team reviews a report that includes PSI-related codes. “Right now, we have a lot of people reviewing PSIs, even though the volume isn’t that high,” she says. “In the long run, this hopefully won’t need to happen, but since it is new to the team, we want as many eyes on the records as possible to make sure we don’t miss anything.”

APL case study
Now let’s walk through the query process. Take this scenario, which Good provided in a recent discussion on “CDI Talk.” The physician documentation stated:

“There was great care taken to avoid injury to the bowel that was directly underneath the skin. The patient did have a chronic wound that had been present since her last surgery in the left anterior abdominal wall. This, in fact, was the serosa of a small intestine. There was no way to avoid injury and serosal tear. This enterotomy was over-sewn using 3-0 Vicryl suture. She had extensive dense adhesions. Lysis of adhesions using Metzenbaum and electrocautery required over two hours. Once this was done, there was another enterotomy that was made. Decision was made to resect these two areas. This was done using an Endo GIA™ 75 Stapler. Two side-to-side anastomoses were performed using the GIA™ 75 Stapler and then a TA™ 60 stapler was used to close the enterotomies. Of note, the central portion [of the bowel] was dilated consistent with prolonged obstruction. The patient had been having significant abdominal pain preoperatively as well as some nausea."  

CDI specialists need to keep in mind that complications should be coded for the patient, not the physician, says Deanne Wilk, BSN, RN, CCDS, CCS, CDI and inpatient coding manager of the HIM department at Good Samaritan Health System in Lebanon, Pennsylvania.

“The fact that it is a quality indicator or the physician may get ‘dinged’ because of it doesn’t mean you don’t code it,” Wilk says. “If the physician says it was unavoidable, that doesn’t mean you should not code it because it was still an issue for the patient.”

The important phrases for CDI staff to watch for, and query for, in this situation are “was this expected or is this to be considered a complication?” says Wilk, and to ask the physician to indicate if this occurred postop and/or intraoperatively.

Had it just been a serosal tear, it might not get coded as an APL, says Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta. However, the issue is the second enterotomy and the unplanned, unexpected resection, he says. “When something unexpected and unplanned occurs that creates tremendous risk so that a resection has to be done, that’s an event and should be coded,” Gold says.

Had the surgeons noted that they “had to resect this stuck segment of bowel to avoid getting into it and potentially contaminating the abdominal cavity” and then did the resection, that would convert it to a planned procedure and alleviate the APL consideration, Gold says.

In response to a high complication rate at her facility, Julie Cruz, RN, CDI specialist at St. Joseph Health in Eureka, California, says her chief medical officer (CMO) requires both CDI and coding to watch for potential complications and to place a query when applicable. If CDI misses the opportunity to query, it becomes the coder’s responsibility to place a retrospective query for clarification.

Anna Rozhkovskaya, RHIT, CCS, CCS-P, CDI manager at Memorial Healthcare System in Miramar, Florida, requires coders to place all cases with potential complications on hold until one of the HIM directors reviews it. If they agree that it is a “true” complication, they send it to the medical affairs director, who then reviews and provides their point of view.

The CDI team then has the opportunity to place a query for the physician or surgeon, if needed. If everyone agrees that it is a complication, the coder will drop the chart.

“It is a very comprehensive process,” says Rozhkovskaya. “Since we now have this process in place, coders don’t just assign complication codes without anyone looking at the chart.”

Kerry Seekircher, RN, BS, CCDS, CDIP, CDI manager at Northern Westchester Hospital (NWH) in Mount Kisco, New York, says CDI reviews these cases in conjunction with the NWH quality department. All cases flagged for having a potential PSI are held for a joint review by CDI and quality. If a determination cannot be made as to whether or not a complication occurred, the physician is queried to provide clarity in the medical record.

“It is best practice for the physician or the surgeon to document if [the laceration] is integral/inherent, necessary, and/or unavoidable,” says Seekircher. “The surgeon should make it crystal clear whether the puncture or laceration was a complication or if it was an expected outcome so that the case can be coded accurately and reflects the care provided.”

As far as education goes, Good includes physicians and surgeons along with CDI and coding.

“Our goal is to reduce and eliminate us being tagged with [inappropriate] APLs, and to be consistent so similar conditions are described the same way,” says Good. “It’s important to be clear with our policies, but also for surgeons to understand that the goal isn’t to get rid of APLs. Every surgeon has a complication rate. The main focus is for us to be consistent with industry guidance and as accurate as possible in the description of what happened to a particular patient.”