Health Information Management

Tip: Coding for inpatient postoperative complications requires explicit documentation

CDI Strategies, July 5, 2012

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Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.
 
Therefore documentation of a postoperative condition does not necessarily indicate a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta. Howard will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on at 1 p.m. (Eastern) Thursday, July 12, for a live audio conference "Inpatient Postoperative Complications: Resolve your facility's documentation and coding concerns."
 
For a condition to be considered a postoperative complication all of the following must be true:
  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication
According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”
 
Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”
 
For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.
 
“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.
 
Editor's Note: This article first published on JustCoding.com. To register for the July 12 program visit www.hcmarketplace.com.



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