Download Those Pesky Variables!

Case Study Pre-op Variables
SQAN October 29, 2013
Answer& Rational
Preoperative Risk Assessment
Chapter 4
• Only preoperative information can be utilized to assign preoperative
variables; unless otherwise specified by the definition.
• Exception: In the scenario where an urgent or emergent surgery is
performed and the situation does not allow for complete preoperative
documentation of a history and physical (H&P), information from the
H&P, which was dictated postoperatively but within 48 hours of the
Principal Operative Procedure, may be utilized to assign preoperative
variables. Such documentation must describe the patient’s previous
medical history. Information derived solely as a result of the Principal
Operative Procedure or established during the postoperative timeframe
may not be utilized, unless a particular variable specifically allows it.
Height
Answer: 175 cm
Criteria: Report the patient’s most recent height documented in the medical record
in either inches (in) or centimeters (cm), within the 30 days prior to the principal
operative procedure or at the time the patient is being considered a candidate for
surgery.
Clinical Support Answer:
Per Chapter 4, postoperative information may only be utilized in an urgent/emergent
surgery where there is no time to complete a pre-op H&P due to the emergent nature of
the case. As the case was emergent, you may utilize the postoperative height, as long as
the H&P was dictated post-op with 48 hours of the principal operative procedure.
Response %
Response Count
175 cm (documented post op)
60 %
15
blank
40 %
10
n =25
Weight
Answer: Pre Op weight
Criteria: Report the patient’s most recent weight documented in the medical record
in either pounds (lbs.) or kilograms (kg), within the 30 days prior to the principal
operative procedure or at the time the patient is being considered a candidate for
surgery
Verified by Clinical Support. Given the fact that there is preop documentation available
for this emergency case, the dietician documentation which occurred postoperative should
not be utilized to assign the pre-operative weight
Response %
Response Count
75 kg (post op)
56 %
14
90 – 91 kg (pre op)
36 %
9
Blank
8%
2
n =25
Points to Clarify at your site
• Source of truth, where do you consistently go
for verification of variables if there is
inconsistency with documentation.
• In the case of an emergency, if there is an
approximate weight pre op and an accurate
weight post op (within 48 hours), what weight
do you use?
Dyspnea
Answer: NO
Criteria: Characterize pt’s dyspnea status when in their usual state of health,
within 30 days prior to operative procedure or time considered a surgical
candidate.
Documentation: The Emergency visit notes describe SOB at rest. This is not the
pt’s usual state of health. Pt previously healthy and is active.
Response %
Response Count
At rest
20 %
5
No
80 %
20
n= 25
Functional Health Status:
Answer: Independent
Criteria: Report the best functional status demonstrated by the patient, within
the 30 days prior to the principal operative procedure or at the time the patient
is being considered a candidate for surgery
Documentation: Due to persistent weakness in left arm requires help from wife for
meal prep and medication prep. Medication and meal prep are not considered
ADL’s. ADLs include: bathing, feeding, dressing, toileting, and mobility
Response %
Response Count
Independent
56 %
14
Partially
Dependent
36 %
9
Unknown
8%
1
n= 25
Hypertension
Answer: Yes
Criteria: The diagnosis of HTN must be documented in the patient’s medical
record and the condition is severe enough that it requires antihypertensive
medication, within 30 days prior to the principal operative procedure or at the
time the patient is being considered as a candidate for surgery. The patient must
have been receiving or required long-term treatment of their chronic
hypertension for > 2 weeks.
Documentation: Pt has a documented history of hypertension and is on Lisinopril
(ace inhibitor)
Response %
Response Count
Yes
96 %
24
No
4%
1
n= 25
Open Wound with or without
infection
Answer: No
Criteria: Preoperative evidence of a documented open wound at the time of the
principal operative procedure.
Scenarios to clarify: Do not assign to
-A scabbed over wound with or without drainage
-A minor wound small enough to be covered by a Band-Aid (break in skin)
Documentation: “ small skin tear right forearm. Edges sl. red, no drainage”
Response %
Response Count
Yes
8%
2
No
92 %
23
n= 25
Steroid Use for Chronic Condition
Answer: No
Criteria: Patient has required the regular administration of oral or parenteral corticosteroid
medications or immunosuppressant medications, for a chronic medical condition, within
the 30 days prior to the principal operative procedure, or at the time the patient is being
considered as a candidate for surgery. A one-time pulse, limited short course, or a taper of
less than 10 days duration would not qualify. Long-interval injections of long-acting agents
(e.g., monthly) that are part of an ongoing regimen would qualify.
Documentation: Meds: Lisinopril 10 mg. po daily, Zoladex q 12 weeks SC –last does 7/01/12,
Coumadin 2.5 mg po daily, Digoxin 0.125 mg po daily.
Response %
Response Count
Yes
4%
1
No
96 %
24
n= 25
> 10% Loss of Body Weight
Answer: No
Criteria: A greater than 10% decrease in body weight in the six month interval immediately
preceding the principal operative procedure manifested by:
-serial weights in the chart
-reported by the patient
-evidence by change in clothing size
-severe cachexia
Documentation: ED pre op note: “ N-V-D X 2 days with a 5 lb weight loss” (not 10% loss)
Dietician note POD # 1: Pt lost approx 15 kg since Jan. unintentionally
Clinical Support: Given the fact that there is preop documentation available for this
emergency case, the dietician documentation which occurred postoperative should not be
utilized to assign the preoperative risk factor of > 10% Loss of Body Weight in the 6 Months
Prior to Surgery.
Response %
Response Count
Yes
52 %
13
No
48 %
12
n= 25
Bleeding Disorder
Answer: YES.
Criteria: Documented diagnosis of a chronic/persistent hematologic disorder or
the administration of medication (anticoagulants, antiplatelet agents, thrombin
inhibitors, thrombolytic agent) that interferes with blood clotting. Scenarios to
clarify:
-If there is no documentation of discontinuation of medication, answer
“Yes” for bleeding disorder. Coumadin stop time is 4 days pre-op.
Documentation: “the patient takes Coumadin 2.5mg daily for A Fib”.
Response %
Response Count
Yes
76 %
19
No
24 %
6
n= 25
Sepsis within 48 Hours Prior to
Surgery
Answer: Septic Shock
Criteria: Report the most significant level (A, B, or C) using the criteria below:
Septic shock is more severe than sepsis. Sepsis is more severe than SIRS. Criteria
must be noted within 48 hours prior to the principal operative procedure:
Documentation: Temp 39, HR 130, RR 32. Purulence in the operative site,
seropurulent fluid present intra-op. “wife states pt has had intermittent confusion
for several hours.”
Response %
Response Count
Sepsis
36%
9
Septic
Shock
64 %
16
n= 25
Report if patient has at least two of the following:
Temp >38 C or <36 C
HR >90 bpm
RR > 20/min
WBC > 12,000 or < 4,000
Anion gap acidosis of either >16 or >12 depending on lab calculation
•
SIRS:

–

–

–
–
–
•
Sepsis: Report if patient meets SIRS criteria as above AND meets scenario 1 or 2:
– Scenario 1:
X • Positive blood culture
X • Clinical documentation of purulence or positive culture from any site for which there is correlating physician
documentation that the site is thought to be the acute cause of the septic picture

–
•
Scenario 2: Suspected preoperative clinical condition of infection which leads to the surgical procedure. The findings
during the operation must confirm the suspected diagnosis and ONE OR MORE of the following:
• Confirmed ischemic / infarcted bowel
 • Purulence in the operative site
• Enteric Contents in the operative site
• Positive intraoperative cultures
Septic Shock: Report if the patient meets both SIRS and Sepsis criteria as above AND:

– Has documented organ and /or circulatory dysfunction.
 • Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress
• Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents.
Summary of Pre-Op Risk Assessment
Pre-Op Risk Factors
Correct Answer
Correct Responses
Height
175 cm
15/25
Weight
90 – 91 kg
9/25
Diabetes Mellitus
No
25/25
Current Smoker
Yes
25/25
Dyspnea
No
20/25
Functional Status
Independent
15/25
Vent Dependant
No
25/25
History of Severe COPD
No
25/25
Ascites w/in 30 days prior No
25/25
CHF w/in 30 days prior
No
25/25
HTN Requiring meds
Yes
24/25
Acute Renal Failure
No
25/25
Currently on dialysis
No
25/25
Con’t Summary of Pre-Op Risk Assessments
Pre-Op Risk Factors
Correct Answer
Correct Responses
Disseminated Cancer
No
25/25
Steroid use for Chronic
Condition
No
24/25
10% loss of body weight 6
months prior to surgery
No
12/25
Bleeding Disorder
Preop Transfusions (RBC
w/in 72 hrs prior to surgery
start time)
Open Wound with or
without infection
Yes
19/25
No
25/25
No
23/25
Septic Shock
Yes
16/25
In/Out Patient Status
Inpatient
25/25
Elective Surgery
No
25/25
Origin Status
Not Transferred (admitted
from home)
25/25
OR Related Variables
Principle Operative Procedure CPT Code
What was the CPT code of the Principle
Operative Procedure?
Response %
Response Count
44060
4%
1
44690
4%
1
44950
4%
1
44960
80 %
20
49060 correct
4%
1
n= 25
Principle CPT code: Answer & Rationale
Intra operative findings: Perforated retrocecal appendix
with extensive retropertioneal abscess involving the right
kidney and extending along the right paracolic gutter to the
level of Morrison’s pouch.
Description
RVU
44060
Sigmoid Myotomy (deleted code)
0
44690
Code does not exist
0
44950
Appendectomy
10.6
44960
Appendectomy for ruptured
appendicitis with abscess or
generalized peritonitis
14.5
Drainage of retroperitoneal abscess;
open
18.53
49060 correct
Other Procedures
This is site specific for what other procedures you capture.
• 44960
Appendectomy for ruptured
appendix with abscess or generalized
peritonitis.
• 49000
Exploratory Laparotomy
**NSQIP recently announced that they will soon be capturing
secondary CPT codes to add to risk adjustment. No
announcement on dates.**
Wound Classification
Answer: Dirty
Definition: Wound classification determines the level of contamination of the surgical wound by
estimating the bacterial load at the surgical site at the time of the principal operative procedure.
-Dirty/Infected:
Old traumatic wounds with retained devitalized tissue and those that
involve existing clinical infection or perforated viscera. This definition
suggests that the organisms causing postoperative infection were
present in the operative field before the operation.
Examples of “Dirty/Infected” cases include excision and drainage of
abscess, perforated bowel, peritonitis, ruptured appendix, gangrenous
gallbladder.
Documentation: A large amount of seropurulent fluid was present. Retrocecally a perforated appendix was
encountered. In the retroperitoneum there was an extensive abscess encountered
Dirty (correct)
Response %
Response Count
100 %
25
n= 25
Post Operative Occurrences
Pneumonia
Answer: Pneumonia assigned on 07/07 , also PATOS
Documentation:
– Pre-op (All on 07/06)
• CXR on 07/06 in ED shows new infiltrate LLL
• Temp 39, SOB at rest, scattered rhonchi
• Cough with new onset of green sputum
• Pt on 2L oxygen
– Post op (All on 07/07)
• Temp: 38.5 overnight, RR 24
• wheezes with bibasilar rhonchi,
• CXR on 07/07 shows no change in LLL consolidation, new consolidation to RLL.
• Pt continues to cough greenish sputum
• Pt on 4 L oxygen.
• WBC = 15
Pneumonia
Criteria: The case must meet Radiology (A) criteria AND ONE of the following TWO
Signs/Symptoms/Laboratory (B) scenarios as listed below within the 30 days after the
principal operative procedure. The criteria should be linked by a period of continuous
symptomatology.

– A. Radiology:
• ONE definitive chest radiological exam (CT or Xray) with at least ONE of the
following:
– New or progressive and persistent infiltrate

– Consolidation or opacity
– Cavitation
 • *Note: In patients with underlying pulmonary or cardiac desease, two or more
radiological exams are required. The two exams should both confirm the
diagnosis or the first exam should serve as a baseline exam which allows the
second exam to establish the definitive new diagnosis
Pneumonia
B. Signs/Symptoms/Laboratory
X • Scenario #1
– At least ONE of the following
» Fever >38 with no other recognized cause
 » Leukopenia <4000 WBC or leukocytosis >12000 WBC
» For adults > 70 years old, altered mental status with no other recognized
cause
X
– AND at least ONE of the following
X » 5% Bronchoalveolar lavage (BAL) – obtained cells contain intracellular
bacteria on direct microscopic exam (e.g., Gram stain)
X » Positive growth in blood culture not related to another source of infection
X » Positive growth in culture of pleural fluid
X » Positive quantitative culture from minimally contaminated lower respiratory
tract (LRT) specimen (E.g. BAL or protected specimen brushing)
Pneumonia
B. Signs/Symptoms/Laboratory
 • Scenario #2
– At least ONE of the following
» Fever >38 with no other recognized cause
 » Leukopenia <4000 WBC or leukocytosis >12000 WBC
» For adults > 70 years old, altered mental status with no other recognized
cause
– AND at least TWO of the following
» New onset of purulent sputum, or change in character of sputum, or
increased respiratory secretions, or increased suctioning requirements
» New onset or worsening cough, or dyspnea, or tachypnea
 » Rales (crackles) or rhonchi
 » Worsening gas exchange (e.g. 02 desaturations), increased oxygen
requirements, or increased ventilator demand
Pneumonia PATOS
Definition: Evidence/suspicion of active pneumonia noted at the time the patient enters the
OR, or intraoperatively.
Criteria: The case must meet the following criteria, A AND B below:
 A. Pneumonia is assigned as a postoperative occurrence
AND
 B. Preoperative data are highly suggestive or suspicious of pneumonia
•
PATOS criteria are frequently less stringent than criteria for an analogous preoperative risk
factor or postoperative occurrence. This means at times PATOS can be assigned to a
postoperative occurrence despite the fact that criteria for a preoperative risk factor may not
be met.
Pneumonia
PNA
Response %
Response Count
Yes
(correct)
76%
19
No
24 %
6
n= 25
PATOS
Response %
Response Count
Yes (correct)
84 %
16
No
26 %
5
n= 19
Date
Response %
Response Count
07/07 (correct)
89 %
17
07/06
11 %
2
n= 19
Clinical Support Answer for
Pneumonia
• Clinical Support Answer:
• Based on the information provided, you would
be able to assign pneumonia to the case. The
patient has 2 CXRs which meet the criteria,
temp, rhonci, and increased 02 requirement.
Urinary Tract Infection
Answer: No
Documentation: there is documentation of signs and symptoms along
with a positive urine culture that support a diagnosis of UTI. There is a
lack of post -op urine culture or post op signs and symptoms to assign
post -operatively.
Response %
Response Count
Yes with PATOS
16 %
4
No (correct)
84 %
21
n= 25
UTI Criteria
•
•
Must be noted within 30 days after the principal operative procedure AND patient
must meet ONE of the following A OR B below:
A: ONE of the following six criteria:
 fever (>38oC or 100.4o F)
urgency
frequency
dysuria
suprapubic tenderness
costovertebral angle pain or tenderness
AND
X A urine culture of > 100,000 colonies/ml urine with no more than two species
of organisms
UTI Criteria
•
Must be noted within 30 days after the principal operative procedure AND patient
must meet ONE of the following A OR B below:
•
B: TWO of the following six criteria:
 fever (>38oC or 100.4o F)
X urgency
X frequency
X dysuria
X suprapubic tenderness
X costovertebral angle pain or tenderness
AND
•
At least one of the following:
•
•
•
•
Dipstick test positive for leukocyte esterase and/or nitrate
Pyuria (>10 WBCs/mm3 or > 3 WBC/hpf of unspun urine)
Organisms seen on Gram stain of unspun urine
Two urine cultures with repeated isolation of the same uropathogen with >100,000 colonies/ml
urine in non-voided specimen
Urine culture with < 100,000 colonies/ml urine of single uropathogen in patient being treated with
appropriate antimicrobial therapy
Physician's diagnosis
Physician institutes appropriate antimicrobial therapy
•
•
•
Intra- / Postop Mycardial Infarction
Answer: Yes
Criteria: An acute myocardial infarction must be noted intraoperatively OR
within 30 days after the principal operative procedure AND one of the following
three scenarios (A or B or C) below:
 A. Documentation of ECG changes indicative of acute MI
B. New elevation in troponin greater than three times upper level
of the reference range in the setting of suspected myocardial
ischemia
C. Physician diagnosis of myocardial infarction
Documentation: Clinical Findings: Cardiology states EKG reveals a ST elevation
indicative of an acute myocardial infarction.
Response %
Response Count
Yes (correct)
Date: 07/08
96 %
24
No
4%
1
n= 25
Sepsis / Septic Shock
Answer: Septic Shock, also assign PATOS
Documentation:
Pre-op:
-Temp 39, HR 130, RR 32.
-“wife states pt has had intermittent confusion for
several hours.”
Post-op:
-WBC 15, Temp 38.5, RR24, HR 94
-abscess and purulence documented in OR report
-intermittent confusion and agitation
Sepsis / Septic Shock
Criteria: Report the most significant level using the criteria below: Septic shock is more
severe than sepsis. Criteria must be noted within 30 days after the principal operative
procedure. Report this variable if the patient meets SIRS criteria (A) AND meets the most
significant level of criterion (B-Sepsis OR C-Septic Shock) below:
A.Five Clinical Signs of SIRS (need two). Plus must met either scenario 1, 2 or 3.
X Scenario 1:
One of the following:
X a. Positive blood culture
X b. Clinical documentation of purulence or positive culture from any site for which there is
correlating physician documentation that the site was thought to be the acute cause of
the septic picture
OR
 Scenario 2:
 -The patient must meet SIRS criteria within 48 hours after the Principal Operative
Procedure AND one of the following findings during the Principal Operative
Procedure:
a. Confirmed ischemic/infarcted bowel (for instance requiring resection)
 b. Purulence in the operative site
c. Enteric contents in the operative site
d. Positive intraoperative culture
Sepsis / Septic Shock
Septic Shock: Report this variable if the patient meets both of the followings:
 1. Sepsis criteria (B) above
AND
 2. Has documented organ and/or circulatory dysfunction.
 -Examples of organ dysfunction include: oliguria, acute alteration in mental
status, acute respiratory distress.
-Examples of circulatory dysfunction include: hypotension, requirement of
inotropic or vasopressor agents.
Sepsis Immediately Post op
Response %
Response Count
Sepsis
28 %
7
Septic Shock
(correct)
28 %
7
Blank
44 %
11
n= 25
PATOS
Response %
Response Count
Yes (correct)
93 %
13
No
7%
1
n= 14
Date
Response %
Response Count
07/06
21.5 %
3
57 %
8
21.5 %
3
07/07 (Correct)
07/08
n= 14
Sepsis at Neverland Hospital
Answer: No
Documentation: SIRS over the “next 10 days” after D/C on 7/12 HR >90; WBC 22.3; Temp
39.0.
Criteria: Report the most significant level using the criteria below: Septic shock is more
severe than sepsis. Criteria must be noted within 30 days after the principal operative
procedure. Report this variable if the patient meets SIRS criteria (A) AND meets the
most significant level of criterion (B-Sepsis OR C-Septic Shock) below:
Five Clinical Signs of SIRS (need two). Plus must met either scenario 1, 2 or 3.
X Scenario 1:
One of the following:
X a. Positive blood culture
X b. Clinical documentation of purulence or positive culture from any site for which
there is correlating physician documentation that the site was thought to be the acute
cause of the septic picture
Sepsis at Neverland Hospital
X Scenario 2:
X -The patient must meet SIRS criteria within 48 hours after the Principal Operative
Procedure AND one of the following findings during the Principal Operative
Procedure:
a. Confirmed ischemic/infarcted bowel (for instance requiring resection)
b. Purulence in the operative site
c. Enteric contents in the operative site
d. Positive intraoperative culture
X Scenario 3:
X -The patient must meet SIRS criteria within 48 hours before or after a subsequent
reopeartion the AND one of the following findings during thesubsequent operation:
a. Confirmed ischemic/infarcted bowel (for instance requiring resection)
b. Purulence in the operative site
c. Enteric contents in the operative site
d. Positive intraoperative culture
Clinical Support Answer for Sepsis at
Neverland Hospital
Clinical Support Answer:
In this instance, the patient would meet criteria to assign postoperative Sepsis if
the SIRS criteria [WBC (18.5) & temp (38.7)] were within 48 hours prior to or 48
hours after the reoperation for the intrabdominal abscess.
If you are unable to determine if the patient met SIRS criteria were within 48
hours prior to or 48 hours after the reoperation for the intrabdominal abscess, as
there is documentation of pus and SIRS criteria there would also need to be
clinical documentation from the physician correlating that the abscess was
thought to be the acute cause of the septic picture.
If you need additional clarification regarding the information received from the
outside office, we would recommend following up with your Surgeon Champion
or the Surgeon who performed the case.
Sepsis at Neverland Hospital
Response %
Response Count
Sepsis
40 %
10
Blank correct
60 %
15
n= 25
PATOS
Response %
Response Count
Yes
40 %
4
No
60 %
6
n= 10
Date
Response %
Response Count
07/16
100 %
10/10
n= 10
Wound Occurrence Immediately
post op
Answer: No occurrence
Documentation: The abdomen was closed with a VAC dressing and the plan was
made to return the patient to the operating room within 48 hours for relook
laparotomy and further debridement Purulence noted during 2nd OR when VAC
drsg was removed documented drainage of intra-abdominal abscess on return to
OR on 07/08/2013.
SSI Guidance – Surgical Wound Closure (From Chapter 4, page 83):
– Can assign an Organ/Space SSI: only if there is/was evidence of interval
resolution of the initial finding of infection, or that the current finding was not
present at the time of surgery or is clearly separate from the finding at surgery
Wound Occurrence at Neverland Hospital
Answer: Organ / Space SSI, also assign PATOS
Documentation:
-Abdominal CT showed reforming of retroperitoneal abscess.
-Patient returns to the OR for a laparotomy and I& D of retroperitoneal abscess.
-No documentation of drainage through the incision.
-The patient's skin was closed during the second OR procedure, this would signify resolution
Criteria: An infection that occurs within 30 days after the principal operative procedure AND involves
any of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated
during the operation AND at least ONE of the following:
A. Purulent drainage from a drain that is placed through a stab wound into the organ/space. This
does not apply to drains placed during the principal operative procedure, which are continually in
place, with continual evidence of drainage/infection since the time of the principal operative
procedure
– B. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space

– C. An abscess or other evidence of infection involving the organ/space that is found on direct
examination, during reoperation, or by histopathologic or radiologic examination
– D. Diagnosis of an organ/space SSI by a surgeon or attending physician
–
PATOS and Organ Space SSI
Answer from Clinical Support: From the information provided, as the patient went on to
develop an abscess following closure of the surgical site, you would assign an organ/space SSI
to this case. As there was an abscess noted during the principal operative procedure, you
would also assign PATOS to this case. There is no documentation to show a period of
wellness.
Definition: Evidence/suspicion of an active organ/space infection noted at the time the
patient enters the OR, or intraoperatively.
Criteria: The case must meet the following criteria, A AND B below:
 A. Organ/space SSI is assigned as a postoperative occurrence
AND
 B. Evidence or suspicion of an abscess or other infection involving the organ or space
manipulated during the operation. This must be noted preoperatively or found
intraoperatively in the surgical space.
Surgical Site Infection (SSI)
Organ Space SSI (correct)
Deep Incisional SSI
Blank
Response %
Response Count
84 %
21
4%
1
12 %
3
N= 25
PATOS
Response %
Response Count
Yes (correct)
95 %
20
No
5%
1
n= 21
Date
Response %
Response Count
07/06; 07/07; 07/08
23 %
5
07/16 (correct)
77 %
17
n= 22
Hospital Discharge Date
Answer: 07/12
Criteria: Enter the date the patient is transferred or discharged from your
hospital’s acute care setting.
Documentation: Discharged from initial hospital on 07/12/2013
Response %
Response Count
07/12 (correct)
96%
24
07/26
4%
1
n= 25
Still in hospital >30 days
Answer: No
Criteria: Patient has a continuous stay in the acute care setting at your institution
> 30 days after the principal operative procedure.
Documentation: Discharged from initial hospital on 07/12/2013
Response %
Response Count
Yes
6%
2
No (Correct)
92 %
23
n= 25
Discharge Destination
Answer: Separate Acute Care
Criteria: Enter the date the patient is transferred or discharged from your hospital’s acute care setting.
Options:
Skilled care, not home (e.g., transitional care unit, subacute hospital, ventilator bed, skilled nursing home)
- Unskilled facility, not home (e.g., nursing home or assisted facility-if not patient’s home preoperatively)
- Facility which was home (e.g., return to a chronic care, unskilled facility, or assisted living which was the
patient’s home preoperatively, prison)
- Separate acute care (e.g., transfer to another acute care facility)
- Rehab
-Home
-Unknown
-Expired
Documentation: Patient discharged to Neverland Hospital for Cardiac care
Response %
Response Count
Home
4%
1
Separate Acute
Care (correct)
84 %
21
Skilled Care, not
home
12 %
3
n= 25
ICD.9
Intent of Variable: To capture information regarding the indication for the
principal operative procedure. In some cases, this information further
stratifies risk.
Definition: The diagnosis code which corresponds to the patient’s condition.
Criteria: Enter the appropriate ICD code corresponding to the condition
noted as the postoperative diagnosis in the brief operative note, operative
report, and/or after the return of the pathology reports
Response
%
Response Count
540: Acute appendicitis with peritoneal abscess
76 %
19
567: Perforated appendicitis and retroperitoneal
abscess
8
2
16 %
4
Blank
n= 25
Post-operative death >30 days
Answer: No
Definition: The date in which the patient expires.
Documentation: No date of death recorded
No (correct)
Response %
Response Count
100 %
25
n= 25
Readmission within 30 days of
Procedure
Answer: No
Intent of Variable: To capture inpatient readmission(s) by midnight of POD 30 and
distinguish between planned and unplanned readmissions at the time of the principal
operative procedure; and to distinguish those that are likely related or unlikely related to
adverse events following the principal operative procedure.
Definition: Patients who were discharged from their acute hospital stay for their principal
operative procedure, and subsequently readmitted as an inpatient to an acute care hospital
setting.
Documentation: Patient was discharged from acute care hopsital to Neverland hospital and
then discharged from Neverland hospital to home
Response %
Response Count
Yes
4%
1/25
No (correct)
96%
24/25
n= 25
Was there an unplanned return to
the OR:
Answer: Yes
Definition: A return to the OR that was not planned at the time of the principal
operative procedure.
Documentation:
-the first return to OR, on 07/08/2013 was for closure of the wound. This was
documented as planned as the patient needed to have primary closure of the
open abdominal wound that was left open intentionally during the initial operative
procedure.
-The second OR, on 07/16/2013, was for a laparotomy for incision and drainage of
retroperitoneal abscess at the Neverland Hospital.
Was there a second unplanned
return to the OR:
Answer: No
Definition: A return to the OR that was not planned at the time of the principal
operative procedure.
Documentation:
-the first return to OR, on 07/08/2013 was for closure of the wound. This was
documented as planned as the patient needed to have primary closure of the
open abdominal wound that was left open intentionally during the initial operative
procedure.
-The second OR, on 07/16/2013, was for a laparotomy for incision and drainage of
retroperitoneal abscess at the Neverland Hospital. This was unplanned.
Was there an unplanned return to the OR for a surgical
procedure, within the 30 days post op period?
Response %
Response Count
Yes (Correct)
96 %
24
No
4%
1
n= 25
Was it
related?
Yes (Correct)
Response %
Response Count
100 %
24
n= 24
Date
07/16/2013
Not asked
Return to the OR CPT Code
Response %
Response Count
49002
4%
1
49020
16 %
4
49060 correct
72 %
18
Blank
8%
2
N= 25
CPT Description
CPT Description
RVU
49002
Reopening of recent laparotomy
1
49020
Drainage of peritoneal abscess or localized
peritonitis, exclusive of appendiceal abscess;
open
26.67
49060
correct
Drainage of retroperitoneal abscess; open
18.53
8%
2
Blank
Neverland Return to OR CPT Coding
49002
is not incorrect as this was done, but
is not an accurate description of the
principle operation performed on the
return to OR.
49020
is not correct as this was a
retroperiotneal abscess, which is
more accurately reflected in code
49060.
30 day follow up
• Correct Answer: No 30 day follow up would be
completed.
• This was not asked on the case study.
Summary of Post Op Occurrences
Post Op Occurrence
Correct Answer
Correct Responses
Pneumonia
Yes
19/25
Pneumonia PATOS
Yes
16/19
Urinary Tract Infection
No
21/25
Intra-/Postop MI
Yes
24/25
Septic Shock Immediate
Post op
Yes
7/25
Septic Shock PATOS
Yes
6/7
Sepsis at Neverland
No
15/25
Organ Space SSI
Yes
21/25
Organ Space PATOS
Yes
20/21
Summary of OR Variables and D/C information
Variable
Correct Answer
Correct Responses
Primary CPT code
49060 (Drainage of retroperitoneal 1/25
Wound Classification
Dirty
25/25
Hospital D/C Date
07/12
24/25
Discharge Destination
Separate acute care
21/25
Post op Death > 30 days
No
25/25
Readmission within 30
days
No
24/25
Unplanned ROR
Yes
24/25
Unplanned ROR Date
07/16/2013
Date not asked
ROR CPT code
49060 (Drainage of retroperitoneal 18/25
30 day Follow up
No
abscess; open)
abscess; open)
Not asked
Organ Space SSI
CPT Code 49060 (ruptured appendectomy); 44960 (retroperitoneal abscess)