When to code a patient as post-op

At the task meeting April 10,2012 we discussed the coding of post-op patients who come from other locations than the OR or PACU.

The question was: When do we include the surgical procedure as part of our diagnosis?

• The decision was made that a specific time frame for including the surgery was not the best way.
• If the recent surgery is relevant to reason for admission then include it in your admit dx as the last code.
• For example a patient had a hip replacement 10 days ago,develops a HAP and is admitted to your unit.The surgery could go in the last diagnostic spot.
• If reason for admission to your ward has nothing to do with recent surgery they don't include it in your diagnosis
• for coding instructions for angiograms see coronary angiogram

Dr Garland feels that collectors judgement is best on when to include the surgery in the diagnosis.

Special Instructions for Concordia Ortho patients:

For Concordia MICU ONLY: If the patient was admitted from the Orthopedic ward and/or had any Orthopedic surgery/procedure during their current hospital admission (regardless of length of time of current admission and/or if moved between multiple centers during current admission); then do include the Orthopedic procedure in the admits (tag in the last admit diagnosis code slot). The reason is that the Concordia Directors are tracking the Orthopedic surgery patients that are being admitted to Concordia ICU. We specifically make sure everyone who has had an Orthopedic surgery during their current hospital stay; and then come to ICU for another reason, will have a tag in the last Admit Diagnosis slot indicating this Ortho surgery/procedure. If the patient is admitted multiple times to the unit during a hospital stay then the same ortho procedure/surgery is included as the last admit diagnosis each time