Health Information Management

Think twice before assigning codes for surgical complications

JustCoding News: Inpatient, March 3, 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, who spoke during a November 20, 2009 audio conference, "Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures." When codes are incorrectly assigned, the complication then appears to directly relate to the surgeon's—or hospital's—oversight, Gold said.

Set the record straight
Until the present on admission (POA) indicator came along, Clarian Health in Indianapolis was reporting multiple complications that weren't entirely accurate, said Lena Wilson, MHI, RHIA, CCS, HIM operations manager at Clarian, who also spoke during the audio conference. "Our academic medical facilities were really getting dinged for these complications when patients actually had them when walking through the door," Wilson said.

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.

Consider this example: A patient undergoes a surgical procedure and then develops subcutaneous emphysema. Before assigning a complication code (998.81), Gold pointed out that there are a whole slew of questions coders must ask. First, coders must determine whether the emphysema was POA. If it was, then it couldn't possibly be a complication of the surgery because the patient had the condition prior to admission.

If it wasn't POA, it could be a complication. When the procedure is elective rather than trauma-related, there is a higher likelihood that this is the case. In the example above, if the emphysema is an incidental finding and doesn't receive specific attention and treatment, coders should not report it at all, Gold said. When in doubt, coders should query the physician, he said.

Coders should ensure that they don't assign a complication code for something that relates to the actual procedure, Gold noted. For example, don't assign code 998.2 (accidental laceration) when a surgeon documents that an enterotomy was made in relation to the insertion of a jejunal feeding tube.

Another area of confusion is deciphering when conditions are postoperative complications of surgery, as opposed to conditions that are not due to the surgery despite occurring during the postoperative phase, Gold said.

For example, documentation of postoperative hypertension could be confusing for coders when the hypertension is actually due to postoperative pain that resolves after the first dosage of pain medication. Without querying the physician, they may be tempted to report a code for cardiac complication of surgery (code 997.1).

Gold often advises surgeons to avoid documenting the term "postoperative" in the postoperative period unless the condition is truly a complication so as to avoid confusion for the coder.

Gold and Wilson said coders should pay attention to the following commonly misreported conditions and note the following guidance and relevant questions:

  • Anoxic brain damage (code 997.01): Before reporting this code, determine whether it occurred preoperatively. Was it caused by the disease itself (e.g., pulmonary embolism or an inhaled foreign body)? Was it due to anesthesia and not the surgery?
  • Heart failure during or after a procedure (code 997.1): Was the heart failure POA? Was it due to the anesthesia and not the surgery? Even when a physician admits a patient for postoperative premature atrial contractions after an outpatient procedure, the physician must specifically state that the condition was a complication of the procedure before a coder can assign code 997.1, Gold said.
  • Peripheral vascular complication (997.2): This code denotes phlebitis or thrombophlebitis during or resulting from a procedure. Coders should determine whether either condition was due to the surgery or an indwelling device, a transfusion, or an IV line before assigning the complication code, Wilson said.
  • Ventilator-associated pneumonia (997.31): Was the pneumonia present before the patient was put on a ventilator? Did it lead to the need for the ventilator? Was the pneumonia POA? The pneumonia may have been the reason the physician inserted the ventilator—not the result of the patient's use of the ventilator, Gold said. Look for clues that might indicate this is the case, such as a positive chest x-ray, mention of the condition in ER physician documentation, or documentation of the condition as a differential diagnosis, he added. 
  • Postoperative stroke (997.02): Was the stroke related to the procedure performed? For example, when a physician operates on a carotid artery and the patient has a stroke after the procedure, it's reasonable that the stroke could be due to the surgery, Gold said. However, if the patient presents for an unrelated surgery, such as the removal of an ingrown toenail, it is highly unlikely the procedure could have caused the stroke. "Clarify with the physician if you have a question about whether it was indeed related to the surgery or whether it was totally unrelated to the surgery," he said.
  • Digestive system complications (997.4): Was the ileus (i.e., temporary arrest of intestinal peristalsis) POA? Was the ileus caused by the disease? When a patient presents with a ruptured appendix and ileus, it's likely that the patient will also have ileus postoperatively, Wilson said. If the physician documents postoperative ileus, it will be coded as a complication when, in fact, the condition was POA and not a result of the procedure for the removal of the appendix. "You really need to work with your surgeons to understand their treatment modalities for ileus," Wilson said. "Was this truly an ileus, or was this patient constipated and the bowel was just slow to return to normal function after the gastrointestinal procedure?"
  • Urinary complications (997.5): Was the urinary retention due to surgery or the patient's preexisting benign prostatic hyperplasia? Did a stone that was POA become symptomatic after a procedure? Was there an underlying condition that wasn't documented initially?
  • Hemorrhage complicating a procedure (998.11): Do not assign hemorrhage as a complication of a procedure when the blood loss is from the disease itself, such as bleeding esophageal varices, angiodysplasia, or a fractured femur.
  • Hematoma complicating a procedure (998.12): Do not assign a hematoma as a complication of a procedure when the physician doesn't treat it and instead discharges the patient in the same time interval as someone with no hematoma.
  • Disruption of internal and external operation (surgical) wound (998.31 and 998.32 respectively): Do not assign these complication codes when the surgeon purposely leaves the wound open. This can occur when the patient has a perforated viscus with gross peritoneal contamination. It can also occur as a temporary measure to prevent abdominal compartment syndrome as in liver transplants.
  • Post-operative anemia due to acute blood loss (285.1): Was it POA? Was it due to blood loss or some other process? "If it's due to blood loss, you have to clarify whether it was due to chronic blood loss from the tumor or acute blood loss from resection of the tumor," Gold said. Ask whether it was due to the disease, a ruptured aortic aneurysm, multiple traumas with liver laceration, or a fracture of the femur. Also ask whether the low level of hemoglobin was due to dilution, and ask whether it resolved without treatment.

Watch for exclusions
Many of the conditions above have detailed and lengthy excludes notes that may require coders to assign other more specific complication codes.

For example, code 997.01 excludes cerebrovascular hemorrhage or infarction (code 997.02). Code 997.1 excludes several conditions that are long-term effects of cardiac surgery or due to the presence of a cardiac prosthetic device (code 429.4). Code 997.4 includes a long list of exclusions that require coders to look elsewhere in the ICD-9-CM Manual when assigning codes. Coders should read the excludes notes before making a final decision regarding code assignment, Wilson said.

Beware of codes for device complications
Not all complication codes denote a complication due to the procedure or surgeon. For example, certain codes denote complications due to devices. Code 996.1 indicates that a catheter tip broke off and caused a complication. Code 996.56 indicates there was a mechanical complication of a peritoneal dialysis catheter, such as when the device shifts and requires repositioning. Code 996.49 indicates there was a mechanical complication of an internal orthopedic device, implant, or graft, such as when loose orthopedic sutures cause pain and must be removed.

"These are really just informational codes that describe the malfunctioning or breakdown of the device itself and are not attributable to anything the physician may have done to cause this to occur," Wilson said.

Editor’s note: This article was originally published in the February issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo at

To learn more about HCPro's November 20, 2009, audio conference, "Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures," go to HCPro’s Healthcare Marketplace.

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