Wiki Question whether to pick up dx for retained foreign body from prev surgery

[AlisonFaught]

I have a question about diagnosis coding - specifically if I should pick up a code for a retained lap sponge from a previous surgery.

The patient has an Exploratory Laparotomy w/ sigmoidectomy and end colostomy. Then 2 days later patient had increasing abdominal distention and heartburn as well as a "dusky" appearing ostomy. Imaging suggests a retained sponge, and it also suggests a post-op ileus. He was taken back to the OR and sponge was removed. The colostomy was found to have clear demarcation of ischemia. The ostomy was sutured closed externally and reduced through the abdominal wall. The ischemic portion of colon was resected and end colostomy revised.

The Post Op Diagnosis on the Op note is "retained foreign body from prior surgery, ischemic end colostomy." I question whether I should code the retained sponge on my physician's claim because the Inpatient Facility coder did not code it on the hospital claim.

 

[csperoni]

If your physician's documentation is that the diagnosis is retained foreign body, that is what I would code.

 

[HReed]

You can add that diagnosis, but beware that many carriers (if not all) actually have a policy to not cover a procedure with evidence of wrongdoing from a previous procedure. This could be the reason the facility did not add this code. My surgeons have always been careful with this type of information.