AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor

Serosal Injury with Excision of Small Intestine

During a laparoscopic salpingo-oophorectomy, the surgeon noted an incarcerated loop of small bowel adherent to a ventral hernia sac. After take down, the bowel was discolored with multiple serosal tears. The incision was then extended, the loop of bowel was brought out through the incision and the segment with the serosal injury was excised. It seems that serosal tears requiring excision would be clinically significant. However, in this case, the provider documented the injury was inherent to the nature of the procedure. On query, he stated the serosal tear was “Unavoidable during extensive lysis of adhesions, not intraoperative complication.” Would any bowel injury requiring excision be considered clinically significant and reportable? How is the serosal injury and repair by excising the small intestine coded? ...

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