AHA Coding Clinic® for ICD-9 - 2010 Issue 1; Ask the Editor

Enterotomy of Small Intestine with Full-Thickness Serosal Tear

The patient underwent lysis of adhesions for small bowel obstruction. Because of the extensive dense adhesions, significant time was spent taking them down from the abdominal wall, pelvis, small bowel and colon. Multiple enterotomies were made dissecting the small intestine. A full thickness injury was identified in a section of small intestine, which could not be repaired primarily; therefore a portion of the small intestine was resected with side-to-side stapled anastomosis. The other enterotomies involving the small bowel were repaired with Lembert style sutures. At the close of the surgery, Seprafilm was placed in the abdomen and pelvis and the operative wound was reapproximated. Coding Clinic, Second Quarter 2007, pages 11-12, stated that a serosal tear should not be coded. In this case, however, the full thickness injury of the small bowel appears to be significant due to the fact that a partial resection of the small intestine was carried out to repair the injury. How should this case be coded? ...

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