For coders, intraoperative serosal tears have become a topic of considerable angst. Are they reportable or not? Now that the AHA Central Office has given new guidance in both the Coding Clinic and the Official Coding Guidelines for FY 2023, we have more tools at our disposal to make our coding decisions – or instead, do we have more subjectivity? Let’s take a look at the issue and then the guidance.

A serosal tear occurs during an abdominopelvic procedure, usually lysis of adhesions, which results in a partial thickness or full thickness injury to the serosa of the intestine.  A partial thickness serosal tear can be repaired with a single layer of sutures and should pass through the serosa and muscular layers.  A full thickness serosal tear can be repaired with a double layered closure with sutures that should include inner layer of mucosa and the seromuscular outer layer.  Some larger defects, thermal injuries, and segments with multiple enterotomies may best be addressed with a bowel resection.

Because of the change to the Documentation of Complications of Care Official Coding Guideline (Section I.B.16), diagnosis and procedure codes may have a significant impact on APR-DRG and MS-DRG assignment as K91.71 is a CC and the repair PCS codes can affect DRG assignment. 

Section I.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 the documentation must support that the condition is clinically significant. 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. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.

A serosal tear during an abdominopelvic procedure is not always clinically significant. Per previous Coding Clinic guidance, the coder was instructed to query the physician if the serosal tear was a complication or inherent to the procedure.  We have now received further guidance in ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2021 pages 11-12 and ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2022 pages 50-51, stating that the surgeon's documentation of the serosal tear and the subsequent significant, course-altering procedure for repairing the tear is sufficient documentation to report a complication code. Also clarified is that the term "complication" does not imply inappropriate/inadequate care, and/or an unplanned outcome.

“The advice previously published in Coding Clinic Second Quarter 2021, page 8, does not conflict with the Official Guidelines for Coding and 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.”

As coding professionals, understanding the coding and reporting of serosal tears is imperative! Not only can it affect diagnosis and procedure code assignment, it also can impact the DRG, SOI, and ROM along with hospital quality scores and patient safety indicators. Understanding the anatomical make-up of the intestine along with the intent of the proposed procedure, the coder can assign the most appropriate diagnosis and procedure codes. Coders should review the operative note in its entirety to determine if a serosal tear should be reported based on the documentation in the record of clinical significance. This is the standard by which our coding will be judged.

Kristy Landry RHIA, CCS, CDIP

Manager, Consulting Services