Health Information Management

Examine postoperative condition coding

Briefings on Coding Compliance Strategies, November 1, 2008

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Just because a physician documents a condition during the postoperative period doesn’t mean coders should code this condition as a postoperative complication. Coders need to make this critical distinction to ensure that their coding is precise and accurately reflects a condition that can affect the hospital’s or physician’s quality scores.

With the increased focus on quality, it is important to report accurate postoperative complications, understand hospital-acquired conditions, and be as accurate as possible when reporting coded data that affect the quality of care a patient received.

“Coders need to know from a surgical perspective what typical outcomes are, and they must also recognize that they can’t code something unless the physician is actively treating it,” says DeAnne W. Bloomquist, RHIT, CCS, president and chief consultant at Mid-Continent Coding, Inc., in Overland Park, KS.

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