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General Surgery Coding Alert

Reader Question:

Complications During a Procedure

Published on Sat Dec 01, 2001

Question: During lysis of adhesions, the patients bowel was inadvertently nicked. Should we report this accidental laceration or are complications that occur during surgery included in the primary procedure?

Delaware Subscriber
 
 Answer: The introduction to the national Correct Coding Initiative, page 3, paragraph 10, states: When a complication described by codes defining complications arises during an operative session ... it is incorrect to report a separate service for treating such complications. An operative session ends upon release from the operating room. Therefore, no separate code should be reported for the repair of a laceration or for treating any other complication during a procedure. If repairing the complication requires significant additional work, some surgeons append the original procedure with modifier -22 (unusual procedural services).
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