Health Information Management

Five tips for coding postoperative or post-traumatic infections with OR procedures

JustCoding News: Inpatient, April 28, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Recovery Audit Contractors (RAC) already are validating countless MS-DRGs in hospitals nationwide, and the number of eligible targets continues to grow. Among the list of approved audit issues for two of the RACs, HealthDataInsights and Connolly Healthcare, are three MS-DRGs on which coders should keep a watchful eye:

  • 856 (postoperative or post-traumatic infection with operating room [OR] procedure with MCC)
  • 857 (postoperative or post-traumatic infection with OR procedure with CC)
  • 858 (postoperative or post-traumatic infection with OR procedure without CC or MCC)

Correct assignment of the principal diagnosis and/or principal procedure will keep RACs at bay, experts say. The following five tips will help ensure compliance:

1. Know which conditions drive these MS-DRGs. The following conditions will yield MS-DRG 856, 857, or 858 when paired with an OR procedure:

  • 958.3 (post-traumatic wound infection, not elsewhere classified)
  • 998.51 (infection postoperative seroma)
  • 998.59 (other postoperative infection)
  • 999.39 (complications of medical care not elsewhere classified, infection following other infusion, injection, transfusion, or vaccination)

Before reporting one of the listed conditions, ensure that documentation supports the fact that a patient truly has a postoperative infection, says Donna D. Wilson, RHIA, CCS, senior director at Compliance Concepts, Inc., in Wexford, PA.

For example, documentation may indicate that a patient has a postoperative fever, but this doesn’t necessarily mean coders should report code 998.59. If the fever isn’t associated with a known infection, report code 780.62 (post-procedural fever), which became effective October 1, 2008.

Similarly, don’t confuse seroma (i.e., a collection of clear fluid) with hematoma (i.e., a collection of blood), says Wilson. Reporting code 998.51 could yield one of the previously listed MS-DRGs whereas reporting code 998.12 (hematoma complicating a procedure) would not.

Reading all documentation before assigning a final code is important, says Wilson. Although physicians may initially document a postoperative infection, they may later determine that the reason for admission after study is actually bacteremia (code 790.7). When assigned as a principal diagnosis with an OR procedure, bacteremia is one of several conditions that drive MS-DRGs 853, 854, and 855 (infectious and parasitic diseases with an OR procedure), she explains.

“If you’re not sure whether it’s a postop infection, you need to query the physician. At the end of the day, you can’t speculate that it is,” says Wilson.

2. Understand how surgical and medical procedures differ. Only surgical OR procedures—when paired with a post-traumatic or postoperative infection—yield MS-DRGs 856, 857, or 858. Medical procedures do not.

Excisional and nonexcisional debridement provide a good example. Although both procedures can be performed at a patient’s bedside, only excisional debridement (code 86.22)—which includes excising devitalized tissue and cutting beyond the wound margins to remove the tissue—is considered surgical (OR procedure). Coding Clinic, first quarter 2008, p. 3 states:

It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure performed. Documentation of excisional debridement should be very specific regarding the type of debridement. If the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification.

Nonexcisional debridement (code 86.28) is nonoperative and includes brushing, irrigating, scrubbing, or washing of devitalized tissue (non-OR procedure). In general, best practice documentation should clearly reflect the size and depth of the wound, the instrument used, and whether the physician removed devitalized tissue, says Wilson.

Another example is incision and drainage of the skin (code 86.04), a non-OR procedure. A patient undergoes a cesarean section and develops cellulitis (a skin infection caused by bacteria) as a result of the surgery. When a surgeon reopens the laparotomy site to address the cellulitis, coders should report code 54.12 (reopening of recent laparotomy site)—an OR procedure.

However, when a surgeon simply incises and drains the skin surrounding the surgical wound without opening the laparotomy site, report code 86.04 (other incision and drainage of skin and subcutaneous tissue)—a non-OR procedure. Correct assignment of the procedure will determine correct MS-DRG assignment and potentially prevent a RAC recoupment as well, says Wilson.

3. Identify documentation and other challenges. Postoperative infections may occur for a variety of reasons, and coders should always be on the lookout for high-risk scenarios, says Marion Kruse, RN, MBA, director at FTI Consulting in Atlanta.

For example, postoperative infections commonly occur in patients who are receiving immunosuppressant drugs, those who use certain asthma inhalers, or those who are receiving chemotherapy, Kruse explains.

The challenge, in general, is that documentation isn’t always explicit, says Kruse.

“[Physicians] will say the patient is admitted with fever, redness, and swelling around the OR site. In this situation, coders must query for more information regarding the presence of infection and whether it is postoperative in nature. The physician has to connect the dots,” she adds.

Documentation also doesn’t typically include an explanation of why the infection occurred or how long the patient has been in the postoperative period, says Wilson. “Physicians will document that a patient is being admitted for incision and drainage of infected skin, and then coders have to figure out when and why they had the surgery,” she explains.

Coding Clinic and CMS don’t provide specific guidance regarding what constitutes a postoperative period; this complicates matters for coders, says Wilson.

4. Be on the lookout for infections due to devices. Some infections that may appear to be postoperative are actually due to a device, implant, or graft. Coders may be tempted to report code 998.59 when they should be reporting a code from the 996.60–996.69 range (infection and inflammatory reaction due to internal prosthetic device, implant, and graft).

For example, a dialysis patient could develop an infection around the fistula—a vascular device formed when a surgeon joins an artery and vein via anastomosis, creating easier and more efficient access to a dialysis machine.

“Any time you have a foreign device in your body, there’s a chance of an infection,” says Wilson. “Sometimes coders think the infection is on the outside of the skin, but it could be due to the actual device.” When the infection in this scenario is truly due to the fistula, coders should report code 996.62 (infection due to arteriovenous fistula or shunt).

Another example is a patient who develops an infection around a pacemaker site. Coders should determine whether the patient simply has an unrelated skin infection around the pacemaker site or whether the infection is due to something internal related to the device itself, says Wilson.

It can become complicated when other conditions mask the underlying cause of the infection, she says. For example, some patients present to the hospital with sepsis that is actually due to an infection from the pacemaker. In this situation, coders should report the infection due to the device—not the sepsis—as the principal diagnosis.

5. Perform proactive audits. Use the Program for Evaluation Payment Patterns Electronic Report (PEPPER) to compare your hospital’s frequency of MS-DRGs 856, 857, and 858 with national averages, says Wilson.

Also pay close attention to documentation and coding accuracy for excisional debridement, Wilson advises, because this may be a compliance sore spot for many hospitals.

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

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Most Popular