Statement on documentation and reporting of accidental punctures and lacerations during surgery

The following statement was developed by the American College of Surgeons (ACS) Committee on Perioperative Care and approved by the ACS Board of Regents at its June 2016 meeting.

The Agency for Healthcare Research and Quality (AHRQ) patient safety indicator (PSI) for accidental puncture or laceration (PSI #15) is a quality measure that reports the rate of inadvertent cuts, punctures, perforations, and lacerations to a patient during a procedure. This quality measure is intended to capture a patient injury that was entirely unintended and caused by medical management rather than by the underlying disease or condition of the patient. These injuries have adverse consequences for patients and are often preventable. Although the indicator has been externally validated, it has been shown to be less predictive of injuries that could be considered clinically important. As a provider-level measure, it is important that surgeons as well as hospital and office coding staff understand how to correctly report this quality measure.

Therefore the ACS recommends the following guidelines for documenting and reporting accidental punctures and lacerations:

  • By definition, PSI #15 is limited to accidental punctures and lacerations that are not intrinsic or inherent to a major procedure. 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. Injuries inherent to a procedure or that are unavoidable due to the structure of the patient’s anatomy or underlying disease process should not be coded with the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes that are covered under PSI #15.* Determination should be based upon the nature of the operative field and operation performed.
  • Although an injury, tear, or repair that was reasonably necessary to perform an operation may not meet the criteria for PSI #15, surgeons should document all intraoperative events. The College encourages surgeons to carefully word operative reports to make it clear whether a puncture or incision is accidental or expected.
  • Regardless of whether codes that are covered under PSI #15 are used, the surgeon should document whether the tear or laceration was significant, whether it required repair, and whether it affected patient care or the patient’s course of treatment or recovery. Documentation in the operative report of tears and lacerations should contain clear, detailed, and specific terminology to communicate the circumstances under which the injury occurred, including the following:
    • A description of the consequences of the laceration or injury
    • Documentation of increased operating time and changes to the intended procedure(s)
    • Documentation of potential increased length of stay due to the complication
    • If an injury was present prior to an operation, that information should be clearly stated in the medical record
  • Surgeons should be available to coding professionals for clarification of the medical record. If the postoperative documentation conflicts with the procedure report, the attending surgeon who performed the procedure must be queried for clarification. Accurate coding is ultimately the responsibility of the surgeon of record.
  • ICD-10-CM has 21 codes indicating accidental puncture and laceration specifying organ or body system and will require increased levels of documentation. As such, surgeons are strongly encouraged to work with hospital staff to ensure proper documentation and coding.
  • Educating surgeons and others to code accurately will result in improved accuracy and enhanced value of this important quality measure. It is highly recommended that coding of this measure by institutions be done in consultation with the primary surgeon to ensure accurate documentation.

Disclaimer

The ACS offers this statement for consideration by surgeons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not constitute a standard of care and is not intended to replace the professional judgment of the surgeon or health care administrator. The statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care organization, and requirements of other allied and health care organizations.

*View a complete list of codes encompassing PSI #15 under ICD-10 online.


Bibliography

Agency for Healthcare Research and Quality. Patient safety indicators: PSI #15, Accidental puncture or laceration. Available at: www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V41/TechSpecs/PSI%2015%20Accidental%20Puncture%20or%20Laceration.pdf. Accessed September 13, 2016.

Agency for Healthcare Research and Quality. AHRQ quality indicators toolkit. Available at: www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/b4-documentationcoding.pdf. Accessed August 30, 2016.

Barney L, Mabry C, Ollapally V, Savarise M, Senkowski C. Reporting patient safety indicator-15. Bull Am Coll Surg. 2014;99(5):39-42. Available at: bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/. Accessed September 13, 2016.

Centers for Disease Control and Prevention. National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification. Available at: www.cdc.gov/nchs/icd/icd9cm.htm. Accessed September 13, 2016.

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. Federal Register. Available at: www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. Accessed September 13, 2016.

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