Two Charts, One Auditor: -ostomy vs -otomy and Sub- vs Supra-
A 71-year-old man with sigmoid diverticulitis undergoes laparotomy. The dictated operative note reads: "The diseased segment was resected, and the proximal bowel was brought out through a circular opening in the left lower abdominal wall and sutured to the skin." Two lines later: "A small opening was made in the transverse colon and closed primarily." The claim was submitted with the code for colotomy. The surgeon's office insists the note documents a colostomy. A second patient's CT report describes an abscess "below the liver, between the liver and the right kidney," but the ordering physician wrote "suprahepatic abscess" in the admission note. Both charts reach the same auditor on a Friday with a 48-hour turnaround.
1. Decide which suffix in the operative note belongs to which sentence, and state whether the submitted colotomy code is defensible.
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Sentence 1 = -ostomy; sentence 2 = -otomy; the submitted code is not defensible.
- -stoma = mouth/opening. -ostomy = surgically creating an opening that is left in place (a stoma). "Brought out through the abdominal wall and sutured to the skin" describes a matured stoma, so the term is colostomy (here, end colostomy accompanying the resection).
- -otomy = cutting into, typically temporary and closed at the end. "A small opening was made... and closed primarily" is a colotomy.
- The resection itself is -ectomy (colectomy), so the full picture is colectomy with colostomy - not a stand-alone colotomy.
Test to apply at the bedside of the note: Is the opening still there at the end of the case? Yes → -ostomy. No, closed primarily → -otomy. Because the code drives reimbursement and the stoma drives ostomy-supply coverage, an incorrect -otomy code has downstream consequences; query the surgeon rather than inferring.
2. Resolve the subhepatic/suprahepatic conflict and say what action is appropriate.
Read the worked answer
The imaging description supports subhepatic.
- sub- = under, below; supra- = above, over. Pair them with hepat/o (liver, Greek) or hepatic (adjective).
- "Below the liver, between the liver and the right kidney" is by definition subhepatic - the region of Morison's pouch. "Suprahepatic" would place the collection above the liver dome, typically subphrenic.
- The prefix is the only differing element; the root and suffix are identical, so the discrepancy cannot be a transcription error of the root. One of the two clinicians has the wrong prefix.
- Action: do not silently correct. Reconcile against the radiology report (the source document with the anatomic description), correct the admission-note term to subhepatic abscess, and issue a physician query documenting the source. Prefix errors flip location and can flip the operative approach.
3. A third note reads: "the two ends of bowel were sewn together." Which suffix would you choose, and why is this not automatic?
Read the worked answer
A sewn-together bowel join is an anastomosis - none of the three suffixes covers it cleanly.
- -rrhaphy = suture/repair (e.g., herniorrhaphy) - used for repairing a defect, not for joining two lumens.
- -pexy = surgical fixation (e.g., nephropexy) - anchoring, not joining.
- -ostomy = creating a stoma; here nothing is brought to the skin, so -ostomy would be wrong.
Judgment point: suffix selection must follow the operative outcome, not the presence of a needle and suture. Because the dictated phrase is generic, the safe move is to query which procedure was performed (end-to-end anastomosis vs. stoma) rather than to attach the nearest-sounding suffix. Choosing -rrhaphy because "sutured" appears in the sentence is exactly the error the note is designed to catch.