Health Information Management

Tip: Perform concurrent review of complication rates

CDI Strategies, May 14, 2009

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Many reported post-operative complications may not really be complications of care at all, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services for 3M HIS, Atlanta. Hospitals request audits to investigate possible mistakes regarding complication rates but after analysis Garrison ultimately finds that the coders have coded the document correctly based on how the physician documented the record.
 
Essentially what happens is that when physicians use the phrase postoperative to mean “period of time” after the operation he or she inadvertently links the documented condition to the procedure performed earlier, Garrison says. In reality, however, the patient may suffer from an adverse effect due to their pain medication or have a pre-existing condition unrelated to the operation which resurfaced during their hospital stay.
 
To combat the confusion, Garrison suggests implementing the following three steps:
  1. Provide additional physician education related to complication coding.
  2. Enhance coder awareness so they will look for conditions that occur frequently but are not related to procedures.
  3. Conduct concurrent review of documentation and query physicians to clarify information when they document post-operative conditions that may be unrelated to the procedures (adverse effects of medications).
“The concurrent review team can work directly with the physicians to get this issue resolved,” she says.



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