Patient Safety Indicator 15 (PSI 15): Abdominopelvic Accidental Puncture or Laceration Rate

By Timothy Brundage, MD, CCDS

Introduction 

The following case study examines complication coding and quality tracking through PSI 15. This is an interesting case that dissects the complicated relationship between clinical medicine, quality metrics and coding compliance. 

Background 

• The patient is an 84-year-old female who presented to the hospital with abdominal pain associated with nausea and vomiting. She was diagnosed with acute cholecystitis but was deemed high risk for surgery. She underwent a percutaneous cholecystostomy tube by IR followed by a laparoscopic sub-total cholecystectomy. During the surgery, she was noted to have a serosal tear during the extensive lysis of adhesions. The tear was repaired during the surgery. 
• The surgeon noted the following: "During her lysis of adhesions a 3mm serosal tear was created in the mid jejunum. This was carefully indicated using a 3-0 silk suture. It took approximately 90 minutes to satisfactorily clear the anterior abdominal wall in the right upper quadrant so that we could appropriately visualize the liver. This lysis of adhesions was beyond what would be expected in a standard cholecystectomy." 

Question

Is this a PSI 15? Will a complication code be reported?

• PSI 15 inclusion is designed to capture and report inadvertent cuts, punctures, perforations or lacerations on patients who have undergone an abdominopelvic procedure, in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. 
• The appropriate coding of a serosal tear in a case like this is complicated, and guidance exists from both Coding Clinic and coding guidelines that are relevant. 

Applicable Guidance 

• From the FY 2022 Coding Guidelines Section 1.B.16
  • Documentation of Complications of Care 
  • 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. 
• Coding Clinic noted the following:
  • ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2022 Pages: 50-51 
  • Reporting for documentation of complication of care (1.B.16.) since a cause-and-effect relationship was documented between the surgery and the serosal tear. This guideline was not intended to mean that the surgeon must specifically document the term "complication." The surgeon's documentation of the serosal tear and the subsequent procedure for repairing the tear is sufficient documentation to report a complication code. 
  • Furthermore, the term "complication" does not imply inappropriate/inadequate care, and/or an unplanned outcome. Some issues or conditions occurring as a result of surgery are classified by ICD-10-CM as a complication whether stated or not.  
  • Although the surgeon stated that the serosal tear was unavoidable, it does not mean that the tear is not a surgical complication. For example, a serosal tear can range from a small nick requiring no treatment at all, to a major tear requiring removal of a portion of the small intestine. 
  • Serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported. 
• Further Guidance
  • In addition, there is a Coding Clinic from AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 4. 
  • 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. 
• We noted conflicting guidance between the most recent Coding Clinic and the coding guidelines.
  • The coding guidelines indicate there must be a cause-and-effect relationship AND an indication in the documentation that it is a complication. This conflicts with the most recent guidance from Coding Clinic. 
  • As noted in the Coding Clinic guidance from 2018, when there is a discrepancy between Coding Clinic and the coding guidelines, the coding guidelines take precedence. There should be clear documentation that the condition is a complication to warrant coding it as such. 
  • In addition, the most recent Coding Clinic guidance notes the serosal tear should alter the course of the surgery as supported by the documentation to be considered a complication. A serosal tear in a complex cholecystectomy that took 90 minutes to clear the abdominal wall is expected and did not alter the course of the surgery. This is corroborated by the surgeon who answered the query as follows: "Serosal tear documented in the operative note was unavoidable due to the density of the adhesions." 

Physician Advisor Opinion 

• This will not be tracked as a PSI 15. 
• This serosal tear is not coded using a complication code.