Note: These sample queries were 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.”
Pt presents with hematuria and perineal pain. MD notes in H/P that a Foley catheter was inserted 3 days PTA for urinary retention secondary to BPH. Temp
104.9, HR 178, RR 48 and BP 80/50. WBCs 20.5 and lactic acid 4.5. Pt given 2L NS bolus, Vancomycin and Cipro IV. H/P notes the following diagnoses:
1. Fever likely due to urinary source
2. Hypotension
3. BPH. I
D consult 2 days after admission notes “likely sepsis”. Daily PN thereafter include diagnoses of sepsis and UTI.
Dear Dr. Foley,
Pt presented with pain and hematuria. Noted in H/P that patient had Foley inserted 3 days PTA. Pt with Temp 104.9, HR 178, RR 48 and BP 80/50. Treatment included NS 2L bolus and IV Vancomycin and Cipro. H/P includes “fever of urinary source”. ID consult 2 days after admission notes “likely sepsis”. Daily PN thereafter list diagnoses of sepsis and UTI.
For accurate reporting of diagnoses, and accurate reflection of the patient’s severity of illness and risk of mortality, please clarify the following:
1.
If UTI is related to/due to/caused by the Foley catheter, other cause, or unknown
2.
If Sepsis is due to the Foley associated UTI, other cause, or unknown
3.
If Sepsis and UTI were present on admission, developed after admission, or unknown

Pt with lung cancer undergoing treatment with radiation and chemotherapy with last treatment 7 days PTA is admitted with fever, generalized fatigue and documented pancytopenia secondary to chemo per H/P. Blood cultures x2 obtained in ED and negative to date. Pt notes that Port-a-cath site painful. H/P documents “probable central line infection” and starts patient on Invanz, Diflucan and Vfend IV.
Dear Dr. Bug,
Patient admitted with fever, fatigue and chemotherapy related pancytopenia per
ED note and H/P. Blood cultures x 2 drawn in ED negative to date. Patient orders include Invanz, Diflucan and Vfend. H/P notes “probable central line infection”
For accurate reporting of diagnoses, and accurate reflection of the patient’s severity of illness and risk of mortality, please clarify meaning of “central line infection” as a.
Localized central line site infection b.
Infected central line c.
Central line associated blood stream infection d.
Other e.
Unknown
Also, please remember to rule in or out this possible diagnosis and if this condition is still possible/probable at discharge to include this diagnosis in your discharge summary.

56 year old woman is admitted with a diagnosis of dysfunctional uterine bleeding for elective total abdominal hysterectomy. Patient is taken to the operating room, where the total abdominal hysterectomy with bilateral salpingooophorectomy is performed. Within the body of the operative report, the surgeon documents that the bladder was accidentally lacerated and repaired.
Dr. Doctor M.D. Gyne,
Documentation within the operative report indicates that the bladder was accidentally lacerated during the abdominal hysterectomy and then subsequently repaired. For accurate reporting of diagnosis, and accurate reflection of the patient’s severity of illness and risk of mortality, please clarify in your progress notes if this was in incidental laceration or a complication of the procedure. Thank you.

Mrs. Klutz is a 62 year old elementary school teacher who accidentally tripped and fell in her classroom, landing on her left hip, while trying to avoid her students rushing out the door at the end of the school day. She was brought to the ER by ambulance with severe pain in the left hip. Xray revealed a displaced fracture of her left femur. She is taken to the operating room and an ORIF of the left femur is performed. Progress note on p.o. day #2 indicates the patient has postop anemia due to blood loss, and the physician orders transfusion of 2 units of PRBCs. The patient refuses the transfusion on the basis of her religious beliefs.
Dear Dr. Bones:
Mrs. Klutz was diagnosed with a fracture of her left femur and is s/p ORIF.
Documentation on 3/29 (postop day #2) indicates patient has postop anemia due to blood loss. For accurate reporting of diagnosis, and accurate reflection of the patient’s severity of illness and risk of mortality, please clarify in your progress notes if this postop anemia was due to expected blood loss, due to an intraoperative hemorrhage, or due to a postoperative hemorrhage, or due to other circumstances (please specify).
A 76-year-old male with a longstanding history of right hip pain secondary to degenerative arthritis was admitted for a total hip arthroplasty. The procedure was complicated by an intraoperative fracture of the calcar and inferior femoral neck. According the operative report, “It should be noted that while impacting the femoral stem down the canal, there was a nondisplaced fracture of the inferior femoral neck/calcar region. This did not extend below the lesser trochanter and for this reason, it was felt that no fixation was necessary because the stem was very stable and this fracture line did not propagate below the tip of the lesser trochanter.” The discharge summary states, “During the procedure there was a nondisplaced crack of the femoral neck/calcar region that did not extend beyond the lesser trochanter and for this reason he was made 50% partial weight bearing.

Dear Doctor Bonez:
Documentation within the operative report indicates that there was an intraoperative fracture of the femoral neck. For accurate reporting of diagnosis, and accurate reflection of the patient’s severity of illness and risk of mortality, please clarify in your progress notes if this fracture was:

A pathological fracture (fracture in a diseased bone due to weakening of the bone structure by pathologic process without any identifiable trauma or following only minor trauma)

Fracture due to intra-operative trauma

Other cause

Unknown
Thank you.
A 56-year-old male with a history of CAD and COPD (per H/P) on home O2 underwent a CABGx3 on 1/1/12. Postoperatively, he had a difficult time weaning from the ventilator and remained on the ventilator until postoperative day 4 when he was successfully extubated to nasal prongs. Daily PN by CV PAon POD
#1-3 indicates a diagnosis of “postoperative respiratory failure.”
Dear Dr Heart,
Mr Jones underwent a CABG x 3 on 1/1/12. Pt also has a history of COPD on home
O2 per your H/P Pt remained on ventilator with daily PN by CV PA includes a diagnosis of “postoperative respiratory failure” on 1/2, 1/3, and 1/4.
Please clarify if the patient’s respiratory is considered a complication/related to the bypass surgery or if the respiratory failure is related to his underlying COPD or other non-surgical cause.

A patient is admitted two weeks after right total hip replacement with WBC
14,500, heart rate 128, temperature 102.5ºF, and blood pressure 101/49.
Physician documents “postoperative infection” in H/P and orders IV antibiotics.
Right hip is tender and incision reddened.
Dear Dr. Joint,
Pt with recent right hip replacement two weeks prior to admission was admitted with WBC 14.5, hr 128 and temp 102.5. Pt started on IV abx. Per H/P, pt has a
“postoperative infection”. If known, please clarify if this infection is a wound infection or an infection of his orthopedic hardware and document in your next progress note. If it is neither, please clarify most specific cause.
A 36 year old male patient underwent surgery for malignant carcinoid tumors of the colon with a resection of the sigmoid and transverse segments of the colon and creation of an ostomy. Postoperative day one the patient’s NG tube remains in draining clear green drainage and MD documents “BS absent”. Postop day two the NGT remains and the physician documents “postoperative ileus”. Postop day three the NGT is removed, patient is started on clears and daily PN from attending notes “postoperative ileus resolved”.
Dear Dr. Bowel,
Pt underwent resection of sigmoid and transverse colon three days ago with creation of ostomy. POD 1 and 2 your PN notes “postoperative ileus”. Today, NGT was removed and pt started on clears. Your PN indicated “postoperative ileus resolved.” Please clarify if the ileus is an expected ileus following surgery or is a complication of the surgery.

An 89 year old female underwent C5-C6 anterior cervical diskectomy and fusion for cervical spondylosis with radiculopathy. Postoperatively, patient was progressing with pain well controlled. Postoperative day three patient is noted to have a rattling cough and temperature of 102.7. CXR performed which shows a
RLL infiltrate and patient is started on IV antibiotics. Later the same day, the patient’s blood pressure drops to 69/32 and patient is resuscitated with 2 liters of
IVF, is started on a Neosynephrine drip and sent to the ICU. Orthopedic attending consults hospitalist for management, who in the consult note documents
“RLL pneumonia and postoperative shock”.
Dear Dr. Fuse,
Patient is four days status post C5-C6 ACD and fusion. On postoperative day three, pt noted to have cough and fever up to 102.7 and was started on IV abx.
That same evening, the patient’s blood pressure dropped to 69/32. Pt received fluid boluses and Neosynephrine IV and sent to ICU. Hospitalist consult note stated “RLL pneumonia and postoperative shock”. For accuracy of reporting, please clarify: a.
Whether the shock is a complication of the surgery, merely occurring in the postoperative period and unrelated to the surgery, other cause, or unknown b.
If the shock is postoperative, please clarify the specific type of postoperative shock:

Cardiogenic

Septic

Other specified postoperative shock

Unspecified cause of postoperative shock

Unknown

Patient is status postop day 3 for adhesiolysis for SBO due to adhesions.
Patient has reported poor pain control and has been reluctant to increase activity or use IS. Patient WBC increased to 13.6K with temperature today of
101.1. MD documents “postoperative fever….Blood and urine cultures to be performed. Will start Levaquin IV.”
Dear Dr. Obstructive,
Noted your patient is postoperative day 3 after lysis of adhesions for SBO. Pt with WBC 13.6K and temp of 101.1. Pt noted to have minimal activity postoperatively, blood and urine cultures obtained and sent, and patient started on Levaquin IV. Your PN today notes postoperative fever”
Please clarify the most likely, possible/probable infectious or non-infectious cause of the patient’s of the patient’s fever and please also indicate if this is related to/due to the patient’s surgical procedure or is merely occurring in the
postoperative period and unrelated to the patient’s procedure.