EmailOversewn serosal tear
Publication Date: May 2021
Implementation Date: 1/06/2021
ICD 10 AM Edition: Eleventh Edition
Query Number: 3700
Patient admitted with small bowel obstruction that required laparotomy and adhesiolysis.
During the procedure a single serosal tear was documented to be ‘oversewn with pds’. A coding query was written to clarify the nature of the tear. The clinician confirmed the tear was an accidental laceration during surgery of the small bowel.
Currently there is no index classification for ‘oversewn’.
Could VICC please advise the:
1. ACHI procedure code for oversewn small bowel?
2. ACHI procedure code for oversewn serosa?
During the procedure a single serosal tear was documented to be ‘oversewn with pds’. A coding query was written to clarify the nature of the tear. The clinician confirmed the tear was an accidental laceration during surgery of the small bowel.
Currently there is no index classification for ‘oversewn’.
Could VICC please advise the:
1. ACHI procedure code for oversewn small bowel?
2. ACHI procedure code for oversewn serosa?
Response
VICC considers the term ‘oversewn’ to mean suture.
If the clinician has confirmed that the tear is of the small bowel serosa, VICC advises to assign 30375-24 [901] Suture of small intestine following Index entry Suture (laceration)/intestine/small.
If the only documentation is oversewing of serosa, VICC advises coders should first confirm the specific site of the serosal tear and then follow lead term Suture and select the specific site.
If the clinician has confirmed that the tear is of the small bowel serosa, VICC advises to assign 30375-24 [901] Suture of small intestine following Index entry Suture (laceration)/intestine/small.
If the only documentation is oversewing of serosa, VICC advises coders should first confirm the specific site of the serosal tear and then follow lead term Suture and select the specific site.
