AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 3; Ask the Editor
Persistent Postoperative Enterocutaneous Fistula
The patient has a history of bowel perforation and obstruction, and is status post complex abdominal surgery due to intestinal anastomotic leak. She was transferred to the long-term care hospital (LTCH) for ongoing care of her abdominal wound. The patient presented with an enterocutaneous fistula with a large open abdominal wound and surgical wound dehiscence. Should the fistula be coded as a persistent postoperative fistula or according to the site of the fistula? ...
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Article Overview
This premium article discusses how to think about coding a persistent postoperative enterocutaneous fistula after abdominal surgery, along with related wound disruption in a long-term care hospital context. It is intended for coding professionals who need to understand the diagnosis coding concepts involved in postoperative complications, fistula site reporting, and wound dehiscence documentation. The article focuses on broad coding guidance for these postoperative findings and the type of supporting information needed to reflect the clinical picture.
Why This Topic Matters
Postoperative complication coding can affect claim accuracy, complication reporting, and the way a patient’s ongoing surgical care is represented. This topic is especially relevant in LTCH and other settings where wound care and postsurgical follow-up remain active issues.
What You Will Learn
- How a persistent postoperative fistula is discussed in relation to the underlying fistula site
- How postoperative wound dehiscence fits into the overall diagnosis picture
- What types of documentation support complication and wound-disruption coding in a postoperative case
- How the LTCH setting relates to the coding discussion
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Health information management professionals
- Long-term care hospital coding staff
Codes Discussed
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