AHA Coding Clinic® for ICD-9 - 2010 Issue 1; Ask the Editor
Enterotomy of Small Intestine with Full-Thickness Serosal Tear
The patient underwent lysis of adhesions for small bowel obstruction. Because of the extensive dense adhesions, significant time was spent taking them down from the abdominal wall, pelvis, small bowel and colon. Multiple enterotomies were made dissecting the small intestine. A full thickness injury was identified in a section of small intestine, which could not be repaired primarily; therefore a portion of the small intestine was resected with side-to-side stapled anastomosis. The other enterotomies involving the small bowel were repaired with Lembert style sutures. At the close of the surgery, Seprafilm was placed in the abdomen and pelvis and the operative wound was reapproximated. Coding Clinic, Second Quarter 2007, pages 11-12, stated that a serosal tear should not be coded. In this case, however, the full thickness injury of the small bowel appears to be significant due to the fact that a partial resection of the small intestine was carried out to repair the injury. How should this case be coded? ...
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Article Overview
This premium article examines coding considerations for an operative case involving lysis of adhesions, multiple bowel injuries, and repair of a full-thickness small-intestine injury. It is intended for coders, coding educators, auditors, and reimbursement professionals who need to understand how coding guidance applies when bowel injury and repair occur during abdominal surgery. The article references Coding Clinic guidance and focuses on the documentation and coding implications of the operative findings without providing the full premium decision analysis here.
Why This Topic Matters
Cases involving inadvertent bowel injury during surgery can affect procedure coding, reporting accuracy, and audit risk. Understanding the distinctions discussed in this article helps coding professionals evaluate similar operative reports consistently.
Article Sections
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Clinical scenario and operative findings
Summarizes the surgical context, including adhesiolysis, bowel injury, and repair activities documented in the operative note.
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Coding Clinic reference and coding question
Introduces the referenced coding guidance and frames the question addressed by the article.
What You Will Learn
- How the operative scenario is framed for coding review
- What kind of guidance is referenced in relation to bowel injury documentation
- Why certain injury details in an operative report may affect coding review
- How the article approaches a question about reporting an intraoperative small-bowel injury
Who Should Read This
- Medical coders
- Coding auditors
- Coding educators
- Revenue cycle professionals
- Compliance staff
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