This Form Is a Permanent Part of the Medical Record

THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD

Addressograph or patient sticker

Request for Documentation Clarification – Bowel Function

Dear Physician/PA/NP: _____________________________ or other responsible provider:

For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

Thank you, on behalf of [insert name], Vice President of Medical Affairs

Please clarify the clinical significance, acuity, etiology, and severity of the findings noted in the medical record. The documentation in the __________________________________________section of the medical record on__________ (insert date) is as follows:

CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________

A diminished return of bowel function is expected in the postoperative period for some patients, and an ileus can have different relationships to the procedure and may not be related to any procedure whatsoever. Please complete this form indicating if any ileus exists and if so, how it should be classified.

MD/PA/NP (Check Any that Apply)

Created: 12/21/11 Revised: 12/23/11

THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD

There is no Ileus for this case

Ileus was present before a procedure and unrelated to procedure

Ileus present before a procedure and due to the disease

Ileus Started after the procedure due to pre-existing disease

Ileus present after the procedure and due to a complication that occurred during the operation. (Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus)

Created: 12/21/11 Revised: 12/23/11

THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD

MD/PA/NP (Check Any that Apply)

An Ileus is present and should be classified as per below - MD/PA/NP (Check Any Below, if applicable)

Created: 12/21/11 Revised: 12/23/11

THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD

Ileus – Adynamic

Due to gallstone

Duodenal, chronic

Mechanical

Due to cystic fibrosis

Myxedema

Postoperative (Complication of Procedure)

Fecal Impaction

Due to Adhesions

Due to Anesthesia

Due to Immobility

Mechanical

Due to other etiology: _____

Created: 12/21/11 Revised: 12/23/11

THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD

Physician/PA/NP Printed Name:______________________________________________________________________

Physician/PA/NP Signature: _____________________________________________Date: __________Time:_______

Posoperative Ileus - Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus. (Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [Medline].)

Definitions Below from Stedman’s

Ileus- Mechanical, dynamic, or adynamic obstruction of the intestines; may be accompanied by severe colicky pain, abdominal distention, vomiting, absence of passage of stool, and often fever and dehydration

Adynamic Ileus - obstruction of the bowel due to paralysis of the bowel wall, usually as a result of localized or generalized peritonitis or shock

Dynamic Ileus - intestinal obstruction due to spastic contraction of a segment of the bowel

Gallstone Ileus - obstruction of the small intestine produced by passage of a gallstone from the biliary tract (usually the gallbladder as a result of cholecystitis) into the intestinal tract (usually by means of a fistulous connection between the gallbladder and the small intestine); occurrence and site of obstruction depend on size of the stone, but the usual location is at or near the ileocecal junction

Mechanical Ileus - obstruction of the bowel due to some mechanical cause, e.g., volvulus, gallstone, adhesions

Meconium Ileus - intestinal obstruction in the fetus and newborn following inspissation of meconium and caused by lack of trypsin; associated with cystic fibrosis

OCCLUSIVE Ileus - complete mechanical blocking of the intestinal lumen

Ileus SUBPARTA - obstruction of the large bowel by pressure of the pregnant uterus

Terminal Ileus - obstruction of the lower part of the small bowel

Verminous Ileus - obstruction due to masses of intestinal parasites

Created: 12/21/11 Revised: 12/23/11