Documentation Tips for General Surgeons
Enterotomies
If an enterotomy occurs during a surgical procedure, it is not considered a complication of the surgery if
one of the following is documented:
• Incidental enterotomy which did not require a complex repair (adding time to OR case or needing
assistance from another surgeon)
• Not clinically significant/clinically insignificant
• Not a complication of the surgery
If an enterotomy occurs during a surgical procedure that does require additional assistance or extends
OR time to repair or is documented as a complication or clinically significant, it will be denoted as a
complication of surgery
Fistulas
Document underlying cause such as:
• Is this due to an infection (type and organism if known)
• Due to a postoperative infection Document type such as:
• Enterocutaneous
• Vesicovaginal
• Vesicocolic
• Postoperative—very important that it is clear if this is after/due a previous surgery
Document associated conditions such as:
• Peritonitis
• Sepsis
• Wound infection/postoperative wound infection
• Infected hardware or mesh Use of the word “postoperative”
Documentation of any condition as “postoperative” automatically identifies it as a complication of the
surgery and will require a query for clarification
• Use postoperative if the complication was due to the surgery or anesthesia used during surgery
• Document all other conditions as “occurring after surgery” or “unrelated to surgery” to avoid an
inappropriate complication being assigned or unnecessary query
• When any provider uses postoperative this still applies—attending can “undo” this by noting in a
subsequent PN and or DC summary that this condition was not a complication of the surgery
Note: This tip sheet was donated Audrey G. Howard, RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer,
and Cheryl Manchenton, RN, BSN, 3M Consulting, adapted from the 2012 HCPro Inc., audio conference
Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding Concerns