AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2023 Issue 4; Clarification

Intraoperative Serosal Tear

A patient underwent laparoscopic right hemicolectomy and adhesiolysis due to extensive adhesions from previous surgery. In the operative report, the surgeon noted, “Small serosal tear of the colon, repaired with suture.” The Official Guidelines for Coding and Reporting, for documentation of complications of care states “It is not necessary for the provider to explicitly document the term “complication. For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code.” Does a serosal tear requiring suture repair meet the definition of altering the course of surgery? Would a minor serosal tear requiring simple suture be coded as a surgical complication? If so, would both the diagnosis of serosal tear as well as the repair procedure be reported? ...

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