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Tip from HIM to our surgeons: The lysis of adhesions

15 Oct 2017

By: Terryn Spragg, RN, CDIS, CCDS, clinical documentation specialist

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We’d like to offer surgeons a suggestion to help with coding, based on this scenario:

After opening up your patient in surgery, you find that their SBO is being caused by extensive adhesions. You lyse the adhesions with cautery and, as a result, it takes you longer to finish the procedure. You chart: “laparoscopic lysis of adhesions in the peritoneum.”

Unfortunately, that isn’t specific enough in ICD-10, so you won’t get any credit for your extra work.

Instead, you need to describe exactly which organ(s) were released during the procedure, their clinical significance (extensive, dense, requiring a long time to lyse, etc.) and whether they were sharply or bluntly lysed. For example: “Laparoscopic lysis of extensive adhesions between the jejunum, bladder and greater omentum were lysed with cautery.” Now all of the procedures performed can be coded, the chart will correctly reflect the severity of the case and everyone can be reimbursed correctly. Specificity of charting for the win!