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Home , Lower anterior resection, Proctoscopy

Anatomy of a Surgical Note: A CSI Analysis of Operative Notes Gone Bad

Frances Frank, MBA, MSN, HCM, RN, CPHQ, CDI Manager Stanford Health Care, Palo Alto, CA Cheryl Manchenton, RN, BSN, Project Manager, Quality Services Lead

3M HIS Consulting, Atlanta, GA1

Disclaimer

This presentation is intended for educational purposes only and does not replace independent professional judgment. The statements and opinions expressed are those of the speakers and, unless expressly stated to the contrary, do not represent the views or opinions of Stanford Health Care. Stanford Health Care does not endorse or assume responsibility for the content, accuracy, or completeness of the information presented.

Agenda

• CSI investigation: Operative note template analysis and code assignment • Meet the defendant: Case example • The trial – Prosecuting attorney case presentation – Defense attorney case presentation • The verdict – Judge’s ruling • The acquittal – Education and collaboration opportunities • Q&A

• At the completion of this educational activity, the learner will be able to: – Approach review of an operative record to identify applicable code assignment – Discuss terminology and template usage with surgeons – Identify conflicting information in the operative record – Identify strategies to collaborate to improve quality outcomes

CSI Investigation

Basic Components of an Operative Note and Associated Documents

A. Procedure section – This section contains a listing of the procedure(s) performed. It is very general. Code assignment should not be dependent on the title of the report. B. Diagnosis(es) preoperatively and postop section – Code assignment should not be based solely on what diagnosis(es) are included in this section. Many times the detailed note has additional information and diagnoses that need to be coded or information that may change code assignment.

Potentially three procedure assignments on case

Components of an Operative Note

C. Detailed operative note section – Every operative note should be read in its entirety to ensure all diagnoses and procedures contained in notes are captured – Also essential to read entire note to determine whether all procedures and conditions are clinically significant or whether a clarification should be placed for significance or to accurately and fully capture the procedure codes • Anatomy • Laterality • Approach • Root operation • Diagnostic vs. therapeutic • Any device insertions

Components of an Operative Note

C. Detailed operative note

D. Findings section – Findings listed may not be noted in the details of the operative report, especially in cases such as bronchoscopies or other diagnostic procedures E. Complications section – Note that this is not the sole determination of whether there were complications. The rest of the medical record and preliminary operative report (if applicable) should be reviewed. – If there is conflict between this section and other evidence or documentation, clarification should be placed. Merely denoting “none” in this section should not be used as “proof” of no complications.

Components of an Operative Note

F. EBL (estimated blood loss) section – What is entered in this section is helpful to determine if there are opportunities to clarify anemia and/or significance of surgical bleeding in conjunction with preoperative H/H G. Postoperative condition section – This section is helpful to review for query opportunities for diagnoses such as hypotension, shock, respiratory issues, possible complications, etc.

Other Related Operative Documentation

• Don’t forget!! – Anesthesia note • Preoperative assessment may include medical conditions not documented by providers that can be captured • Review for use of pressors, vital signs, fluid boluses, etc. for possible query opportunities – PACU note • Review for hemodynamic status, respiratory status, bleeding, neurologic issues, etc. – Anesthesia postoperative evaluation note • Review for any adverse effects of the surgery or anesthesia, etc.

• Variety: Freestyle, templates • Surgeons have been known to dictate operative reports at different times. With that comes pros and cons. – Some “batch dictate” at various frequencies, e.g., at the end of a surgical day, once a week, once every two weeks, once a month (ouch!), once they receive “nastygrams” from medical record department that they are delinquent (30 days after discharge) (= big ouch!!) – Some dictate after every surgery

Meet the Defendant: Low Anterior Resection Case Example

First Surgeon’s Procedure Title: 1. Laparoscopic low anterior resection of the rectum with stapled side‐to‐end descending colon‐to‐rectal anastomosis at 5 cm from the anal verge 2. Laparoscopic mobilization of the splenic flexure

Operative Report Detail Regarding Surgical Approach: “We made a 7 cm suprapubic incision and deepened it into the skin and subcutaneous tissue. This was taken down to the anterior rectus sheath. The fascia was incised and the peritoneal cavity entered. A GelPort was placed. With my hand in the abdomen a 10 mm trocar was placed in the supraumbilical position and a pneumoperitoneum was achieved to 15 mm Hg using carbon dioxide. Two additional working trocars were placed.” Supports code assignment for laparoscopic portion of procedures “After freeing up the left colon, our attention was turned to the pelvic dissection. The GelPort was removed leaving the Alexis retractor in place ... (operative note details rectum removed—see subsequent slides) Supports code assignment for open portion of procedures “We then replaced the GelPort and reconstituted the pneumoperitoneum”

• “We did a laparoscopic‐assisted low anterior resection of the rectum with a side‐to‐end descending colon‐to‐rectal 5 cm from the anal verge after full mobilization of the splenic flexure.” 0DTNOZZ Resection of sigmoid colon, open approach • “We divided the mesentery to the descending/sigmoid junction with the LigaSure. The colon was divided with a GIA 75 mm stapler. The proximal colon was packed into the upper abdomen. The rectum was retracted anteriorly entering the presacral space. The hypogastric nerves were identified an traced out the pelvic side‐walls bilaterally. The lateral peritoneal attachments of the rectum were incised as was the anterior peritoneal refection. Using sharp dissection under direct vision, the rectum was mobilized outside of the fascia propia of the rectum down to the pelvic floor. The rectum was then divided between a firing of the TL‐30 mm stapler and a 2‐inch right‐angled Glassman clamp.”

First Operative Note Details: 1. Laparoscopic low anterior resection of the rectum with stapled side‐to‐end descending colon‐to‐rectal anastomosis at 5 cm from the anal verge

Evidence that the entire rectum was not resected (removed) “We chose a soft spot on the descending colon for our proximal resection margin. We then evaluated perfusion of the colon with the SPY system … perfusion of the colon was excellent. We divided the mesentery with the LigaSure. There was excellent pulsatile blood flow in the marginal artery. We made a colotomy in the specimen and inserted the anvil of an Ethicon 29 mm EEA stapler into the descending colon. The post was brought out through the antimesenteric side of the colon and secured in place with a 3‐0 Vicryl purse string suture. The colon was divided with the GIA 75 mm stapler and the specimen passed from the field.” B410110 Fluoroscopy of 0DBPOZZ Excision of rectum, abdominal aorta using low open approach osmolar contrast

First Operative Note Details:

Supports that an excision of rectum (partial No code assignment for anastomosis body part) was performed instead of a as it is integral to the procedure, but resection (entire body part) supports sigmoid colon resected

“Given the lack of a qualified resident I asked for xxxx MD’s assistance stapling the anastomosis. She inserted the head of the Ethicon 29 mm EEA stapler transanally. It was opened up anterior to the transverse staple line. After insuring proper orientation, the anvil was connected to the stapler. It was closed and fired creating a stapled side‐to‐end descending colon to rectal anastomosis. The anastomosis was 5 cm above the anal verge.”

“Because of the low lying nature of the anastomosis we elected to create a proximal diverting loop ileostomy … We chose a loop of small bowel approximately 20 cm proximal to the cecum.” 0D1B0Z4 Bypass ileum to cutaneous, open approach

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 6 These materials may not be copied without written permission. Second Procedure Note Title: 1. Laparoscopic low anterior resection of the rectum with stapled side‐to‐end descending colon‐to‐rectal anastomosis at 5 cm from the anal verge using Ethicon 29 mm EEA stapler 2. Proctoscopy 0DJD8ZZ Inspection of lower intestinal tract, endoscopically 3. Mobilization of splenic flexure

Second Procedure Note Details:

“The head of the stapler was then passed transanally and opened up anterior to the transverse staple line of the rectum. After insuring proper orientation, the anvil was connected to the stapler. It was closed and fired creating a stapled side‐to‐end descending colon to rectal anastomosis.”

No code assignment as it was previously documented in other operative note but supports sigmoid colon resected

Case Code Assignments Based on Operative Notes

Principal diagnosis: C20 Malignant neoplasm of rectum

Procedures: 0DTN0ZZ, Resection of sigmoid colon, open approach (complete removal of sigmoid colon) 0DBP0ZZ, Excision of rectum, open approach (partial removal of rectum) 0D1B0Z4, Bypass Ileum to cutaneous, open approach (ileostomy) 0DJD8ZZ, Inspection of lower intestinal tract, endoscopic via natural orifice (proctoscopy) B410110, Fluoroscopy of abdominal aorta using low osmolar contrast (use of SPY for patency of perfusion)

• You are the surgeon. How should this case be coded? – Open rectal resection – Laparoscopic rectal resection – Open rectosigmoid resection – Laparoscopic rectosigmoid resection – Other – I don’t know (no code book or encoder)

The Trial: Prosecuting Attorney’s Presentation

The Charges

• Case coded as a sigmoid resection – “Coding obviously is coding these cases wrong” – “The same surgery is performed almost every time” – “The template used is perfectly clear and easy to read” – “You are ruining our quality scores”

The Defense

• Case coded as a sigmoid resection – HIM: • “We coded what the provider documented” • “We have to code what is documented and can’t interpret an intended meaning of a provider” – CDI: • “There is no impact on the surgical DRG assignment” – Quality: • “Our surgical site infections for colon surgeries look bad and the surgeon is not happy about” it

The Verdict: Judge’s Ruling

• Cases involving the rectum are “dirty” cases and those involving the sigmoid are “clean” – “Dirty” cases are excluded from surgical site infection (SSI) rates of colon cases • CDC requires the reporting of SSI rates of colon cases • Included in Hospital‐Acquired Condition (HAC) Reduction Program (HACRP) and Value‐Based Purchasing (VBP) performance metrics • May inadvertently affect accuracy of infection rates for organization – Low anterior resection (LAR) cases have to be clearly documented as to the extent/portion the sigmoid was involved

The Verdict

• Provider profile impact – Physician profiling includes publicly reported infection rates; and some physician professional associations monitor for infections (i.e., NSQIP, STS) • “Dirty” cases (rectal) with ambiguous documentation about the extent the sigmoid was involved may lead a coder to assign colon codes. However, since colon cases are supposed to be “clean” cases, the result is a falsely higher infection rate on what appears to be a colon case. • Is a surgeon’s infection rate truly due to provider skill versus the need for more clear documentation? – Surgeons are additionally measured on rates of open versus laparoscopic approaches • Higher‐than‐expected open cases reporting skews provider data

The Verdict

• “Alienation of affection” – Adversarial relationship between providers, HIM, CDI, service line administrators and quality – Can be disseminated across the organization and can prevent collaboration and program improvement, as well as affect provider response rates

• Does your organization have strong collaboration? – Always – Usually – Sometimes – Rarely – Never – Are you kidding me?

The Acquittal: Educational and Collaboration Opportunities

Education Opportunities

• Read all pertinent and associated Coding Clinics • Read entire question and answer to determine if the scenario presented applies to current case • Review for language such as “supersedes previous advice” • Note that we have guidance to use ICD‐9‐CM advice for ICD‐10‐CM/PCS scenarios

General Advice

• There is no better substitute for understanding the surgery – Educate about the type of procedure performed • CDI: Ask the surgeon to help you understand • Request surgical observation; surgeons love to teach! • Go to your medical library, online medical references, Google search, etc. • Coders review PCS training resource material – Repetition, repetition, repetition

Low Anterior Resection ICD‐9‐CM Coding Clinic, First Quarter 1996, Page 9 Question When a physician performs a lower anterior resection of the rectum, part of the sigmoid is also excised. Would the sigmoidectomy be considered an integral part of the surgery? Would it be appropriate to assign both code 48.63, Low anterior resection of the rectum, and code 45.76, Sigmoidectomy?

Answer Assign code 48.63, wLo anterior resection of rectum. The Alphabetic Index (Volume 3) directs the coder here and the sigmoidectomy is included in the code assignment since the excision of the sigmoid is an integral part of the total surgery.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 12 These materials may not be copied without written permission. Low Anterior Resection versus Sigmoid Resection; ICD‐9‐CM Coding Clinic, Third Quarter 2010, Page 12 Question The title of the operative report listed "low anterior resection of the colon." The surgeon indicates that the colon was pulled down, and there was more than adequate length for resection of the entire sigmoid colon along with a little of the left colon and a little bit of the rectum. A purse‐string stapler was fired across the end of the descending colon. The specimen was then resected and removed. A 33 mm stapler was obtained, and the anvil was placed in the end of the descending colon and the purse‐string suture was tied.

Low Anterior Resection versus Sigmoid Resection; ICD‐9‐CM Coding Clinic, Third Quarter 2010, Page 12

The other end of the stapler was then passed into the rectum and the post perforated through about the midpoint of the staple line of the rectum. The two ends were attached, closed, and fired. The bowel was clamped, and then ssome air wa insufflated into the rectum, through the anus, with some water in the pelvis. There was no air leak. Irrigation was then performed, and the fascia was then closed. What is the correct code assignment for this surgery? Is the documentation of "a little of the rectum" enough to assign a code for low anterior resection of the rectum?

Low Anterior Resection versus Sigmoid Resection; ICD‐9‐CM Coding Clinic, Third Quarter 2010, Page 12

Answer: Assign code 45.76, Open and other sigmoidectomy, for the procedure. Based on the operative report, the surgeon carried out resection of the sigmoid colon. A low anterior resection was not done. A low anterior resection involves a resection deep in the lower pelvic region.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 13 These materials may not be copied without written permission. Low Anterior Resection Clarification ICD‐9‐CM Coding Clinic, Second Quarter 2012, p. 21 Question: Coding Clinic First Quarter 1996 stated that a low anterior resection of the rectum includes a sigmoidectomy and the sigmoidectomy is not coded separately. Additionally, Coding Clinic Third Quarter 2010 stated that a low anterior resection involves a resection deeper in the lower pelvic region. These citations appear to be providing clinical information about what constitutes a low anterior resection versus a sigmoidectomy. Our facility is seeking further clarification regarding which procedural components represent a true low anterior resection?

Low Anterior Resection Clarification ICD‐9‐CM Coding Clinic, Second Quarter 2012, p. 21

Answer: Query the provider regarding the specific procedural components involved in a low anterior resection. The previously published advice was not intended to establish clinical parameters as to what constitutes a true low anterior resection. Any clinical information published in Coding Clinic is intended to aid the coder's understanding and to offer “clues” to identify possible gaps in documentation where additional provider query may be necessary. It is not intended to replace the need for specific provider documentation to substantiate code assignment.

Abdominoperineal Resection; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2014, pp. 40–41 Question: A 57‐year‐old male with low rectal cancer presents for abdominoperineal resection (APR) of the rectum with reconstruction to follow. A cylindrical APR was performed, along with excision of the sigmoid colon and resection of the anus. Should the excision of the sigmoid colon and resection of the anus be reported separately?

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 14 These materials may not be copied without written permission. Abdominoperineal Resection; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2014, pp. 40–41 • Answer: Yes, the resections of the rectum and anus as well as the excision of the sigmoid colon are separately coded. To capture the entire surgery, all three codes are required. Assign the following ICD‐10‐PCS codes: – 0DTP0ZZ Resection of rectum, open approach – 0DTQ0ZZ Resection of anus, open approach – 0DBN0ZZ Excision of sigmoid colon, open approach

Note this Coding Clinic does not apply as the question noted that sigmoid colon was resected.

Applying Past Issues of AHA Coding Clinic for ICD‐9‐CM to ICD‐10; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2015, pp. 20–21 • The Central Office on ICD‐10‐CM and ICD‐10‐PCS has received numerous requests to advise users how past issues of AHA Coding Clinic for ICD‐9e‐CM ar to be utilized in the ICD‐10 environment. In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD‐9‐CM, and remain applicable for ICD‐ 10‐CM with some caveats.

Applying Past Issues of AHA Coding Clinic for ICD‐9‐CM to ICD‐10; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2015, pp. 20–21

• For example, Coding Clinic may still be useful to understand clinical clues when applying the guideline regarding not coding separately signs or symptoms that are integral to a condition. Users may continue to use that information, as clues—not clinical criteria. • As far as previously published advice on documentation is concerned, documentation issues would generally not be unique to ICD‐9‐CM, and so long as there is nothing new published in Coding Clinic for ICD‐10‐CM and ICD‐10‐PCS to replace it, the advice would stand.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 15 These materials may not be copied without written permission. Applying Past Issues of AHA Coding Clinic for ICD‐9‐CM to ICD‐10; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2015, pp. 20–21

• Previously published ICD‐9‐CM advice that is still relevant and applicable to ICD‐10 will continue to be re‐published in Coding Clinic for ICD‐10‐CM/PCS. As with the application of any of the coding advice published in Coding Clinic, the information needs coding advice published in Coding Clinic, the information needs be reviewed carefully for similarities and differences on a case by case basis. Care must be exercised as the codes may have changed. Such change could be related to new codes, new combination codes, code revisions, a change in nonessential modifiers, or any other instructional note.

Applying Past Issues of AHA Coding Clinic for ICD‐9‐CM to ICD‐10; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2015, pp. 20–21

• This is particularly true as ICD‐10‐CM has many new combination codes that were not available in ICD‐9‐CM. For example, previous Coding Clinic for ICD‐9‐CM advice has indicated that hypoxia is not inherent in chronic obstructive pulmonary disease (COPD) and it could be separately coded. Coders should not assume this advice inevitably applies to ICD‐ 10‐CM. The correct approach when coding with ICD‐10‐CM is to review the Index entries for COPD, and determine whether or not there is a combination code for COPD with hypoxia, verify the code in the Tabular List, and yreview an instructional notes.

Applying Past Issues of AHA Coding Clinic for ICD‐9‐CM to ICD‐10; ICD‐10‐CM/PCS Coding Clinic, Fourth Quarter 2015, pp. 20–21 • The coder should then determine whether to code the hypoxia separately—and not automatically assume that a separate code should be assigned. • In order to simplify the learning process, when the Cooperating Parties developed the ICD‐10‐CM guidelines, every attempt was made to remain as consistent with the ICD‐9‐CM guidelines as possible, unless there was a change inherent to the ICD‐10‐CM classification. If a particular guideline has remained exactly the same in both coding systems, and Coding Clinic for ICD‐9‐CM has published an example of the application of that guideline, it's more than likely that the interpretation would be similar.

General Suggestions for Provider Collaboration and Education • Be multidisciplinary – CDI, HIM, quality, service line administrators, surgeons – Level set pertinent coding guidelines and procedural coding requirements – Use actual operative notes with code assignments » Provide example of modified documentation – LISTEN to their concerns – Attempt win‐win scenarios – Provide the WIFM (what’s in it for me?)

Potential Changes to Existing Templated List of alternate words to be Operative Note provided by organization 1. Laparoscopic low anterior resection of the rectum with stapled side‐to‐end sigmoid colon‐to‐rectal anastomosis at 5 cm from the anal verge 2. Laparoscopic mobilization of the splenic flexure

“We did a laparoscopic assisted low anterior resection of the rectum with a side‐to‐end sigmoid colon‐to‐rectal 5 cm from the anal verge after full mobilization of the splenic flexure.”

“We divided the mesentery to the ? Sigmoid/rectal junction with the LigaSure. The extreme distal end of the sigmoid colon was divided with a GIA 75 mm stapler. The proximal sigmoid colon was packed into the upper abdomen, the rectum was retracted anteriorly entering the presacral space. The hypogastric nerves were identified and traced out the pelvic side‐walls bilaterally. The lateral peritoneal attachments of the rectum were incised as was the anterior peritoneal refection. Using sharp dissection under direct vision, the rectum and remnant of sigmoid colon was mobilized outside of the fascia propia of the rectum down to the pelvic floor. The rectum was then divided between a firing of the TL‐30 mm stapler and a 2t‐inch righ ‐angled Glassman clamp.”

Operative Note List of alternate words to be provided by organization

“We chose a soft spot on the extreme distal sigmoid colon for our proximal resection margin. We then evaluated perfusion of the colon with the SPY system … perfusion of the sigmoid colon was excellent. We divided the mesentery with the LigaSure. There was excellent pulsatile blood flow in the marginal artery. We made a colostomy in the distal sigmoid colon and inserted the anvil of an Ethicon 29 mm EEA stapler into the sigmoid colon. The post was brought out through the antimesenteric side of the sigmoid colon and secured in place with a 3‐0 Vicryl purse string suture. The sigmoid colon was divided with the GIA 75 mm stapler and the specimen passed from the field. “

Suggest that if any portion of the above note was done with GelPort intact that template specify this as well.

Potential Changes to Existing Templated

Operative Note List of alternate words to be provided by organization

“Given the lack of a qualified resident, I asked for xxxxxx MD’s assistance stapling the anastomosis. She inserted the head of the Ethicon 29 mm EEA stapler transanally. It was opened up anterior to the transverse staple line. After insuring proper orientation, the anvil was connected to the stapler. It was closed and fired creating a stapled side‐to‐end sigmoid colon to rectal remnant anastomosis. (If no rectal remnant change template to sigmoid colon to anal anastomosis) The anastomosis was 5 cm above the anal verge.”

“Because of the low lying nature of the anastomosis, we elected to create a proximal diverting loop ileostomy via GelPort … We chose a loop of small bowel approximately 20 cm proximal to the cecum.”

Potential Changes to Existing Templated Operative Note List of alternate words to be provided by organization

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 18 These materials may not be copied without written permission. Potential Case Code Assignments With Alternate Documentation

Principal diagnosis: C20 Malignant neoplasm of rectum

Procedures: 0DBP4ZZ, Excision of rectum, laparoscopic (partial removal of rectum) 0D1B4Z4, Bypass Ileum to cutaneous, laparoscopic approach (ileostomy) 0DJD8ZZ, Inspection of lower intestinal tract, endoscopic via natural orifice (proctoscopy) B410110, Fluoroscopy of abdominal aorta using low osmolar contrast (use of SPY for patency of perfusion)

Process Change Pitfalls

• Meetings, meetings, meetings! • Too many chiefs and not enough Indians • Physician buy‐in (or lack thereof) • Leadership changes • “Agree to disagree” • Technology issues • Lack of top‐down communication on process change • Lack of version control • Lack of monitoring of process change

Thank you. Questions?

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