Surgical misadventures versus Complicated Operative Episodes: Conundrums and Smell Tests

Discerning between a more complex operative episode and one in which an unexpected medical misadventure or complication occurred is not as easy as it sounds.

First, a warning: the following is mostly an opinion piece, and does not represent anyone’s opinion but my own.

The American Hospital Association (AHA) just threw a monkey wrench into the works by changing what should be a very simple and easy task into one both difficult and complicated. The task I am referring to, simply put, is this: ensuring that clinical documentation integrity specialists (CDISs) , surgeons, and coders are able to do their due diligence in making sure that routine surgical events don’t inadvertently get reported as medical misadventures. If you are thinking “this should not be controversial,” you would be correct – and you would also be incorrect.  

As it turns out, discerning between a more complex operative episode and one in which an unexpected medical misadventure or complication occurred is not as easy as it sounds, for the following reasons:

• ICD-10 indexing often takes you directly to the complication code when no complication occurred, especially if you index on the terms “post-op” or “post-operatively.”
  1. Misadventure codes are the ICD-10 default index entries when events are described as having occurred after surgery, which most subject matter experts in the field now believe to be an incorrect application of misadventure codes in general use.
  2. In fact, the ICD-10 Official Coding Guidelines clearly state that “a complication is not a complication unless the MD states it is a complication.”

Section 1.B.16 of the Guidelines states:

“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.”

Did you notice the loop hole? You could be forgiven if you missed it. The above paragraph leaves itself an out. First, they say that the provider’s documentation of the relationship is necessary before code assignment can be completed accurately, and then they add in the phrase “unless otherwise instructed by the classification.” What does the classification do? It often tries to pull the indexing into a medical misadventure even when that isn’t clinically accurate. This gets us caught in a logic loop if we overthink it.

Now would be an excellent opportunity to point out that there is a hierarchy of coding advice wherein, in the event of a contradiction or conflict, the Official Coding Guidelines supersede anything the AHA says. Who says that? Well, the AHA, for one:

Fourth Quarter ICD-10 2018, Pages 90-91: “When there is a discrepancy between the conventions in the classification, the guidelines and/or advice published in Coding Clinic, coding professionals should adhere to the following hierarchy: conventions in the ICD-10-CM and ICD-10-PCS classification take precedence over the Official Guidelines for Coding and Reporting, and both the classification and guidelines take precedence over Coding Clinic advice.”

• Reading operative notes isn’t always easy. Surgeons may simply comment that a rent, cut, or laceration was somewhere in the operative field and needed to be additionally repaired, but without any comments as to if this was planned, routine, integral, or unexpected. This leaves the coder and often the CDS scratching their heads and debating the various merits and surgical techniques, of which we are obviously not discerning subject matter experts (even if we can probably make a cogent argument that we are often more qualified to do it than the minions writing denial letters on behalf of the payors). But wait, Coding Clinic solved this problem by leaving the decision up to the surgeon, right?

• Very recently, Coding Clinic for the second quarter of2021 inexplicably rendered even this judgement as a quagmire of debate:

“Question: During a laparoscopic salpingo-oophorectomy, the surgeon noted an incarcerated loop of small bowel adherent to a ventral hernia sac. After takedown, the bowel was discolored with multiple serosal tears. The incision was then extended, the loop of bowel was brought out through the incision, and the segment with the serosal injury was excised. It seems that serosal tears requiring excision would be clinically significant. However, in this case, the provider documented (that) the injury was inherent to the nature of the procedure. On query, he stated the serosal tear was ‘Unavoidable during extensive lysis of adhesions, not intraoperative complication.’ Would any bowel injury requiring excision be considered clinically significant and reportable? How is the serosal injury and repair by excising the small intestine coded?

Answer: Assign code K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure, for the serosal injury of the small intestine. Although after query the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery.”

(Disclaimer: first, let me say that if you do not have your own subscription to Coding Clinic, please subscribe. You should not be treating our discussions of the coding rules as a substitute for receiving advice in the full issue, as distributed by the AHA. For all of our criticisms, if they didn’t put in the hard work they do, we wouldn’t even have this starting place for our debates. We would have something akin to the “wild west,” as they say.)

Now, having said that, this advice from the AHA puts us in a serious conundrum. One, because it seems to contradict the Official Coding Guidelines (and attempts to violate the hierarchy), and two, because as a general rule, we have to follow all official guidance (and this is Official). Allow me to also attempt to theorize on why Coding Clinic may have commented this way. While this is just my opinion, I believe that the crux of their motivation may have extended from the level of severity implied by the decision to have to convert into a colectomy, which is far more extended than the typical bowel repair that we had previously been arguing was routinely associated with many surgeries performed in the area adjacent to the intestines (and of which the choice to name as integral or unexpected was left to the discretion of the surgeon).

While I disagree that the intensity of the remedy is officially part of the paradigm of determining when something should be reported as a misadventure versus routine, I certainly can understand their root motivation for this particular matter, in the case of this particular operative episode. To quote, “the bowel was discolored, with multiple serosal tears … (and) the loop of bowel was brought out through the incision and the segment with the serosal injury was excised.” To that end, it would have been extremely helpful if the AHA had elaborated more about both the unusual nature and severity of the condition of the bowel in this instance, and also of the unique intensity of the remedy required for this specific patient in their explanation – and the relationship to their rationale for which the advice to use a complication code was based upon, in this specific case.

Unfortunately, we now are faced with a potential avalanche of unwarranted medical misadventure codes being reported in clinical situations much less significant than the one in the specific example given.

Moreover, if that particular portion of the bowel was in particularly poor condition prior to the surgeon needing to do their work (discolored with dense adhesions and potential ischemic indicators), then even the partial colectomy wouldn’t be a medical misadventure or complication of the surgery, because it would have been pre-existing at the time of the operative episode. That would make it just a more complicated patient presentation requiring correction, nothing more. 

This is a good segue into a discussion about how to start these conversations with our attending physicians and surgeons. If you are looking for some kind of an unofficial starting point to move these conversations forward in a rational way (and note, this is unofficial), you can start by applying some of these yes/no logic tests to the operative episode to figure out where you stand and what makes rational sense. For example:

1. 1. Was it known that this would likely happen, prior to surgery?
   2. Is the issue in question a “routine occurrence?”
   3. Was the patient informed that this would likely happen as a matter of course during consent?
   4. Did the event place the patient at additional risk of morbidity/mortality or extend length of stay above and beyond their pre-operative status predictions?
   5. If unexpected, did the patient require a higher-acuity recovery location or other increased hospital resource use (longer-than-expected hospital stay, etc.) as a result (again, irrelevant if this was planned in advance).
   6. Were any unexpected surgical consultations or surgeons brought in because of the event?
   7. Were there unexpected blood transfusion or other intra-operative resources (devices, pressors, temp pacemakers, grafts, etc.) brought in that had been unplanned?
   8. At any point during the surgery were the words “oops,” “oh crap,” “well, that’s not good,” “call vascular/neuro,” or “well that sucks” uttered by the guy holding the knife or running the robotics? Or was the discussion more along the lines of something like this: “yeah, we are going have to go through here. This intestine looks bad. I’ll just have to spend some extra time patching.”

Likely, you’ll know where the situation stands by answering these questions, and you can use this thought process or something similar to work through the discussion with your physician advisor and/or surgeon. Perhaps you could build something akin to a clinical decision tree here as part of the hospital internal policy.

When it comes to these contradictory pieces of official advice, arbitrary use of “yes, these are always complications/no, they are never complications” are not helpful in real-world practice.

These “smell tests” can be used to set up an honest conversation with your physician leadership in a way that should help you further align the goals of proper reporting with the surgical truth – assuming clinical truth and accuracy are still the ultimate goals of the reporting industry.

Programming Note: Listen to Allen Frady report this story live today during Talk Ten Tuesdays, 10 Eastern.