Health Information Management

Think twice before assigning codes for surgical complications

HIM Connection, February 16, 2010

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CDI programs can greatly enhance documentation, but what happens when a hospital's risk-adjusted complication index and/or risk-adjusted mortality index rise as a result of perceived complications that aren't actually complications?
 
This can happen when coders report complication codes for conditions that are unrelated to the surgery or that existed prior to the surgery, said Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. When codes are incorrectly assigned, the complication then appears to directly relate to the surgeon's—or hospital's—oversight, Gold said.  
 
Until the Present on Admission indicator came along, coders at Clarian Health in Indianapolis was reporting multiple complications that weren't entirely accurate, said Lena Wilson, MHI, RHIA, CCS, HIM operations manager at Clarian. "Our academic medical facilities were really getting dinged for these complications when patients actually had them when walking through the door," said Wilson.
 
Although Wilson noted that the POA indicator helped paint a more accurate picture, another piece of the puzzle was to educate coders about what truly constitutes a complication. 
 
Note: For more information, visit the HCPro Web site. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the February issue of the newsletter.



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