Post-op Complication or Not?

[DrGold]

A 68 year old male was brought to the hospital having dropped from a ladder onto his feet and fractured his tibia and fibula. He was operated with open reduction of closed fractures and application of a cast. Nurses noted his abdomen was distending and he was given an enema with slight results. He was discharged to home, only to return to the ED in two days with greater abdominal distension. Called a postoperative ileus, he was enemized and given Colace and bowel stimulants. In 48 hours, he was back in with significant distension, having had minimal stool. X-ray showed considerable dilation of the entire colon. Air was also noted in the wall of the cecum. "Pseudo-obstruction/paralytic ileus" was diagnosed and the patient was prepared for colonoscopy and suction of the excessive air. Temperature was 99.6 and white count rose to 13,500 with 11% bands.

Should this be assigned the codes for intestinal complication of procedure and (post-operative) ileus?

[afletcher]

I think it could be a complication of the procedure but my other thought is that due to the mechanism of injury with him falling and landing on his feet, the force of the impact is transmitted upward and maybe compressed the vertebral bodies and he sustained some sort of neurogenic problem causing his intestinal complications. I am probably way off on this but couldn't there be something undiagnosed that is going on?

[Jgold]

No complication code should be assigned as the ileus had nothing to do with the surgery. The cause of the ileus will be the principal diagnosis (possibly perforated colon cancer).

[Drew S.]

The severity of his symptoms and the fact that his procedure did not involve the abdominal cavity, makes me reluctant to assign this as a procedural complication without further information. The fact that he has evidence of an inflammatory/infectious process with fever and a high WBC count with bands and air in the colon wall, raises the possibility of conditions such as acute mesenteric ischemia or toxic megacolon (especially if he has a history of inflammatory bowel disease).
Certainly, orthopedic procedures (especially major ones like hip surgery) can result in colonic pseudo-obstruction and there is the possibility that the combination of the original trauma, the surgery and possible use of narcotic pain medications all resulted in an acute pseudo-obstruction (Ogilvie Syndrome). It would be up to the attending physician to determine the cause of the condition and document the relationship, if any, to the recent surgery before this is considered to be a post-procedural complication. Unless the attending physician say’s it is a result of the surgery, I would not code this as a complication but I would ask for further clarification, especially if the term “status post” is used. The surgeon might mean that surgery was done but that the present event is not considered a complication.

[DrGold]

Well, welcome to a new doc, lending his GI expertise to the Forum.

As some of you correctly identified that, if the doc didn't touch it, he couldn't harm it. Operating on an ankle won't cause the complication of surgery of ileus. It doesn't matter if the physician used the term "postoperative" or not. Coding advice states that, if it's not clear, DON'T assign the complication code without asking the surgeon if he caused it.

Stuff happens to people, whether undergoing ankle surgery, riding a tank or sleeping though the second half of the super bowl. That's what happened to our unfortunate patient. He had acute mesenteric ischemia - specifically blocking a branch of the superior mesenteric artery that supplies the cecum - and that's what led to the virtually pathognemonic finding of air in the wall of the bowel. The surgery had noting to do with it.

Yay!

Dr. G.