The Agency for Healthcare Research and Quality’s (AHRQ) patient safety indicator (PSI)-15 for accidental puncture or laceration is a quality measure that is intended to gauge and report a physician’s rate of inadvertent cuts, punctures, perforations, and lacerations during a surgical procedure.1 The American College of Surgeons (ACS) sought clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the correct reporting of PSI-15. At the crux of the ACS’ concerns is the lack of clarity as to what constitutes an “accident.” Punctures or lacerations that occur in surgical procedures often are incorrectly coded as “accidental” when the puncture or laceration was, in fact, a natural consequence or part of the operation.
The importance of seeking clarification on PSI-15 was spurred by CMS’ decision to include both PSI-15 and PSI-90, a hospital measures group that includes PSI-15, in several CMS quality reporting programs, including the Inpatient Hospital Reporting Program, the Hospital Value-Based Purchasing Program, and the Hospital-Acquired Conditions Reduction Program. Although PSI-15 currently is used in CMS programs that measure and report the quality and performance of hospitals, PSI-15 itself is a provider-level measure, which means that the results of PSI-15 can be attributed to the physician rather than the facility. At present, the results of PSI-15 are not separately reported as part of these CMS quality programs; however, surgeons for whom PSI-15 is inappropriately reported could be affected based on how their facilities are conducting their internal quality improvement efforts. In addition, it is unclear how CMS, private payors, and hospitals will use PSI-15 in the future. For these reasons, it is important that hospital and office coding staff understand how to correctly report this quality measure.
CMS acknowledged and responded to the ACS’ concerns regarding this measure in the fiscal year 2014 inpatient prospective payment system (IPPS) final rule.2 More specifically, CMS finalized proposals to include PSI-15 in the three hospital quality reporting programs identified previously, but the agency maintains that the concerns about what constitutes an accidental puncture or laceration can be alleviated with proper coding guidance. Hence, in the final rule CMS responded that, “according to explicit guidance from the [American Hospital Association’s] Coding Clinic for ICD-9-CM (Second Quarter, 2007 and First Quarter, 2010), ‘expected’ enterotomies are not coded with code 998.2. By definition, this code is limited to ‘accidental’ punctures and lacerations that are not ‘intrinsic’ or ‘inherent’ in a major procedure.”2
Although the CMS guidance is straightforward, the ACS has received comments from Fellows indicating that some hospital quality reporting departments continue to misunderstand how to correctly report PSI-15. This column provides more background and coding guidance to assist surgeons in working with their hospital staff on reporting PSI-15.
As indicated in CMS’ response, proper reporting of PSI-15 hinges on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 998.2: “Accidental puncture or laceration during a procedure, not elsewhere classified.” In addition to clarification regarding the term “accidental,” it is important to know that ICD-9-CM 998.2 explicitly excludes iatrogenic [postoperative] pneumothorax (512.1); puncture or laceration caused by implanted device intentionally left in operation wound (996.0-996.5); and specified complications classified elsewhere such as: broad ligament laceration syndrome (620.6), dural tear (349.31), incidental durotomy (349.31), and trauma from instruments during delivery (664.0-665.9).3
Hospital coders use this ICD-9-CM code predominantly for general surgery cases, but also for otolaryngology, urology, gynecology, neurosurgery, gastrointestinal, cardiology, internal medicine, and other cases. It is important to note that hospital coders should not report this ICD-9-CM code when punctures or lacerations are “expected.”
PSI-15 is a measure that generates a ratio of reported events. The denominator includes most surgical and medical discharges, with a few exclusions. The numerator is intended to capture accidental cuts, punctures, perforations, or hemorrhages during medical care and is triggered when the hospital codes 998.2. Therefore, if a hospital handles “expected” punctures or lacerations correctly by not coding 998.2, the ratio of accidental punctures or lacerations per discharge will not be inappropriately diminished and will be more accurate.
When hospitals report 998.2 as an additional diagnosis, it counts as a complication or comorbidity (CC) or a major complication or comorbidity (MCC). The billing of CCs or MCCs often contributes to a higher diagnosis related group (DRG), resulting in increased reimbursement for the hospital. Given that hospitals could have an incentive to report 998.2 in order to increase reimbursement, it is important that hospital coders, who are primarily responsible for determining whether to report 998.2, understand how to use it correctly.
AHA coding guidance
As noted in CMS’ response to the ACS’ concerns, the American Hospital Association (AHA) Coding Clinic for ICD-9-CM sought to clarify the issue regarding punctures and laceration in response to providers’ questions. The following questions and answers are taken from two AHA Coding Clinic publications.4,5
AHA 2007 guidance
Question: The patient presented with a left upper quadrant retroperitoneal cystic mass, involving intra-abdominal organs, and was brought to the operating room where she underwent radical excision of retroperitoneal cystic mass with adrenalectomy. During the procedure, the surgeon noted “a small capsular injury of the spleen, which was hemostatic.” This injury did not require repair. An esophagogastroduodenscopy (EGD) was then performed for evaluation of the distal esophagus since the mass had adhered at the gastroesophageal junction. The EGD revealed a serosal injury to the stomach, which was repaired with interrupted Lembert sutures. The surgeon did not include the intraoperative tears in the diagnostic statement. What are the appropriate code assignments?
Answer: Query the provider, and if the provider states the tear is not clinically significant, omit codes for both the diagnosis and procedure. When a tear is documented in the operative report, such as a small serosal tear of the stomach, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure. If the provider documents that the seromuscular tear is a complication of the surgery, assign code 998.2, Accidental puncture or laceration during a procedure, as an additional diagnosis. This advice is consistent with that previously published in Coding Clinic, Third Quarter, 1990, page 18.
Note: this advice differs from that previously published in Coding Clinic, First Quarter, 2006, page 15, regarding dural tear occurring during surgery. The dural tear was coded in that case, because a dural tear is always clinically significant due to the potential for cerebrospinal fluid leakage.4
AHA 2010 guidance
Question: 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?
Answer: Assign code 560.81, Intestinal or peritoneal adhesions with obstruction, as the principal diagnosis. Code 998.2, Accidental puncture or laceration during a procedure, and code E870.0, Accidental cut/puncture/perforation/hemorrhage during surgical operation, should also be assigned. For the procedures, assign code 54.59, Other lysis of peritoneal adhesions; code 45.62, Other partial resection of small intestine; code 45.91, Small-to-small intestinal anastomosis; code 46.73, Suture of laceration of small intestine, except duodenum; and code 99.77, Application or administration of adhesion barrier substance, for the placement of the Seprafilm.
This case involved more than a minor serosal tear. In this instance, the surgeon has clearly documented that the multiple enterotomies were clinically significant and a complication of the procedure.5
ACS coding experts disagree with the premise of the 2010 AHA guidance—that the degree of penetration of the bowel determines whether the occurrence is incidental to the operation or is an accidental injury. Rather, the determination should be based upon the nature of the operative field and operation performed. For example, during an adhesiolysis in a densely adherent abdomen, multiple full thickness small bowel repairs and resections might be expected if the surgeon documents that the enterotomies are intrinsic or inherent to the procedure of freeing the bowel. In contrast, puncture of the bowel by a Veress needle during creation of a pneumoperitoneum in a previously unoperated abdomen would be considered accidental and reportable.
The ACS encourages surgeons to carefully word operative reports to make clear whether a puncture or incision is accidental or expected. If the “injury” to a structure is expected, then the surgeon should use language such as:
- “The adjacent organ was densely adherent to the tumor. In order to obtain adequate margin around the malignancy, the serosal surface was necessarily incised and removed, and the defect was closed.”
- “Adhesiolysis was difficult. As expected, multiple serosal tears and full thickness enterotomies were created during mobilization of the bowel, then were repaired with….”
- “At this point in the operation, entry into the normal adjacent bowel was unavoidable. This segment of bowel was resected and reanastomosed in two layers.”
In addition, if a surgeon is operating to repair an iatrogenic perforation or other organ injury, whether from a previous operation or from another procedure (such as a vascular access, an endoscopic procedure, or a diagnostic procedure) that resulted in the injury, he or she should clearly state in both the diagnosis and in the indications paragraph that this injury was present before the operation he or she is currently reporting. This clarification is necessary to prevent hospital coders from assigning 998.2 to a procedure when the accidental puncture or laceration is related to a previous procedure.
The ACS also encourages surgeons to work with hospital staff to ensure proper coding. Using ICD-9-CM code 998.2 in situations where the puncture or laceration is expected and not accidental would be inappropriate use of the ICD-9-CM code and could negatively affect a hospital’s and surgeon’s quality reports. Appropriate use of ICD-9-CM code 998.2 will contribute to a more accurate picture of both the hospital’s and surgeon’s quality of care and also give the Medicare program and patients more useful quality measurement information.
If you have questions or comments regarding this column, contact Vinita Ollapally at firstname.lastname@example.org or 202-672-1510. If you have additional coding questions, contact the ACS Coding Hotline at 800-227-7911 between 8:00 am 5:00 pm, CST, excluding holidays.
Accurate coding is the responsibility of the provider. This summary is only a resource to assist in the billing process.
- Agency for Healthcare Research and Quality. Patient safety indicators: PSI #15, Accidental puncture or laceration. Available at: http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V41/TechSpecs/PSI%2015%20Accidental%20Puncture%20or%20Laceration.pdf. Accessed March 28, 2014.
- Centers for Medicare & Medicaid Services. Medicare program; Hospital inpatient prospective payment systems for acute care hospitals and the long term care; Hospital prospective payment system and fiscal year 2014 rates; Quality reporting requirements for specific providers; Hospital conditions of participation; Payment policies related to patient status; Final rule. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. Accessed March 28, 2014.
- Centers for Disease Control and Prevention. National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification. Available at: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD9-CM/2011/. Accessed March 28, 2014.
- American Hospital Association. Coding Clinic for ICD-9-CM, Second Quarter, 2007. Chicago, IL: American Hospital Association;11-12.
- American Hospital Association. Coding Clinic for ICD-9-CM, First Quarter, 2010. Chicago, IL: American Hospital Association; 11-12.