Abdominopelvic Accidental Puncture or Laceration Rate
In the CMS Hospital Acquired Condition (HAC) Reduction Program, there are 10 Patient Safety Indicators (PSI) including abdominopelvic accidental punctures and lacerations (PSI-15) that comprise the composite PSI-90 score. PSI-15 is intended to capture the rate of inadvertent punctures or lacerations in adult patients who have undergone an abdominopelvic procedure AND subsequently require a second abdominopelvic procedure1.
Important Coding Guideline Update
Recent updates in coding guidance no longer require a surgeon to label a condition as a “complication” to support the assignment of a complication code. Further, even if the surgeon states a serosal tear was unavoidable and is “not a complication,” according to recent Coding Clinic updates2: “The surgeon’s documentation of the serosal tear and the subsequent procedure for repairing the tear is sufficient documentation to report a complication code.” The updated advice states, “serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported.”
Prior to this guidance, surgeons were advised to describe an accidental puncture or laceration as unavoidable or inherent to the procedure. Due to updated guidance, this is now insufficient to avoid the reporting of a complication code and possible inclusion into PSI-15. Surgeons must now clarify if a laceration or puncture alters the course of surgery.
If the complexity of a patient’s anatomy resulted in a minor tear that did NOT significantly alter the course of surgery, the complication code will NOT be reported. However, if a tear alters the surgery, i.e., bowel/organ resection, then a complication WILL be reported.
A patient with a history of multiple prior abdominal surgeries undergoes a procedure for lysis of adhesions in which a serosal tear occurred. Documenting that “the serosal tear was repaired with simple suture and did not alter the course of surgery” will avoid the reporting of a complication code and possible inclusion in PSI-15.
Download the complete tip, Patient Safety Indicator (PSI) 15.
1-AHRQ Patient Safety Indicator 15 Technical Specifications
2-ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2022 Pages: 50-51