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Avoid the push and pull when reporting complications of surgery

Association of Clinical Documentation Improvement Specialists, September 9, 2009

Reporting complications of surgery is often likened to a tug of war between hospitals and physicians. Hospitals need to be fairly compensated for patients who suffer unexpected events during surgery, since these patients require more resources to treat and require a longer hospitalization. But physician profiles and quality scores on sites like Healthgrades.com suffer negatively from over-reporting of these diagnoses. The push and pull of these opposing forces makes life difficult for the average CDI specialist trying to do his or her job.
 
“We teach hospitals to look at the documentation and the patient’s severity, but then when you get to the physician’s side, these 900 [complication] codes may have negative ramifications in reference to their profiling,” says Mario A. Perez, III, RHIA, CCS, CCS-P, director of coding and documentation compliance for J.A. Thomas & Associates in Atlanta, GA.
 
Coding vs. clinical conundrums
From a coding perspective, reporting complications is relatively straightforward. According to the ICD-9-CM Official Guidelines for Coding and Reporting, a coder must report the complication first. For example, if a patient has a post-operative ileus following bowel surgery as documented by the physician, a coder would report post-operative complication code 997.4 followed by 560.1—provided that the ileus did not exist pre-operatively, and was not an integral part of the surgery, says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, GA. “If there’s any doubt, clarify with the physician,” he says.
 
If the physician documents that the ileus was a normal physiologic response to handling the intestine (i.e., the physician documents ‘expected ileus secondary to bowel surgery’), and if it did not prolong the hospital stay, the coder would only report 560.1. On the other hand, if the patient developed abdominal distension and vomiting, and a nasogastric tune was reinserted, then the “postoperative ileus” went beyond the normal physiologic expectations and 997.4 would be appropriately assigned.
 
However, from a clinical perspective, the issue of what is a complication versus an expected outcome of surgery is often unclear. Following are some examples.

Hemorrhage complicating a procedure (998.11) and acute blood loss anemia (285.1). In a patient admitted with a long bone fracture, for example, there will be considerable loss of blood into the thigh as a result of the fracture. This blood loss happens whether the patient goes to the operating room or not and, indeed, the hematocrit may drop low enough to meet the definition of anemia, notes Gold.

CDI specialists should work with the physician to determine whether the complication is a true post-operative complication, or the result of an expected event of the disease rather than of the surgery. If the patient’s anemia is the result of a long bone fracture and the patient is treated for it, 285.1 may be appropriately assigned by coding staff.

If the documentation is unclear, CDI specialists should ask the physicians the following question: “Do you consider this anemia due to blood loss from the long bone fracture, or was it a complication from the surgery?” If the former is true, 285.1 is the correct code to report, and if the latter is true, 998.11 may also be appropriately reported.

In contrast, when a true hemorrhage occurs—an unexpected laceration of a major artery in the pelvis, for example—998.11 is appropriate.

“If the patient has a ruptured aortic aneurism or an operative procedure for a major trauma, 285.1 would be expected, and 998.11 is likely inappropriate,” Gold says.

CDI specialists should consider queries for complications of surgery due to unexpected events, such as an unexpected drop in hemoglobin. “If you see an operation that’s not associated with blood loss, for a disease problem that’s not associated with blood loss, and suddenly you see the patient’s hemoglobin drop in the chart, there’s likely a problem,” Gold says.

Postoperative respiratory insufficiency (518.5): This is another problem diagnosis, Gold says. Some intensivists identify conditions as acute, critical care conditions when the patient is just being reversed from anesthesia, resulting in inappropriate assignment of 518.5, Gold says. “It’s inappropriate to ask the doc to document these things, and a lot of documentation improvement consultants train their students to do this,” he says. It results in an MCC for the hospital but results in a massive ‘ding’ for the surgeon.”

In addition, many physicians elect to document “acute respiratory failure” in the above circumstance, leading to an inappropriate code assignment of 518.81 (acute respiratory failure). “Either one—518.5 and 518.81—is inappropriate to report for mere reversal from anesthesia,” Gold says.

Gold says a good rule of thumb for postoperative respiratory insufficiency is to avoid querying physicians for the condition in planned instances of recovery, or as components of the surgery. Some examples of inappropriate reporting of 518.5 include the following:

  • A patient has his or her wound packed open, is placed on a ventilator, and will be sent back to the OR the next day to complete a planned, staged procedure
  • A coronary artery bypass graft (CABG) or valve replacement patient comes out of the OR and it takes 3-4 hours to get the patient off a ventilator while he or she is being reversed from anesthesia

In addition, many secondary diagnoses are components of a larger disease and thus should not be reported using complication codes. For example, patients with a ruptured bowel generally show up with a tight abdomen, absent bowel sounds, and an elevated white count. Frequently they have ileus and sepsis—and when they come out of the surgery, they still have ileus and sepsis, and remain on antibiotics.

“The question is, was it the surgery that caused the ileus, or the ruptured bowel?” Gold says. If it’s the latter, the ileus should not be reported as a complication, but should be reported as present on admission (POA) or clarified for its POA status.

In addition, all surgeries require some degree of routine postoperative treatment, and thus should not be separately reported. For example, patients who undergo abdominal surgery typically don’t resume normal functioning of their large intestine for three days after the surgery.

“When the surgeon writes on day one, ‘postoperative ileus,’ a coder may assign it to get the CC and the surgeons will get inappropriately [penalized] for it,” Gold says. Why is a complication code inappropriate in this instance? Paralytic ileus occurs in all patients who have major bowel surgery, he says, and they all get treated the same way.

“There is no additional utilization of resources, or observation, or anything different from the usual major bowel case,” says Gold. “It should not be reported at all. It does not meet UHDDS criteria as a valid secondary diagnosis.”
 
Another classic example is patients who, after undergoing surgery for a coronary artery bypass graft, are administered Dopamine to maintain blood flow through the kidneys following the operation. “Some people will look for postoperative shock in order to get a major CC—but everyone gets the Dopamine,” Gold says. “Don’t look for stuff like that just to get a major CC—it hurts the surgeon and it’s not a valid code.”
 
Non-reporting runs risk of noncompliance
In order to avoid conflicts with their physician staff or sidestep tricky clinical questions like those referenced above, some hospitals elect to sidestep the issue by not reporting complication codes. But Perez says this decision places facilities in non-compliance with coding regulations. When hospitals elect not to report complication codes, it reflects poorly on the facilities’ length of stay, since patients with complications from surgery often require more resources and additional days in the hospital. 
 
“Besides, the hospital now stands out as the only one that reports no complications—and that’s enough to lead to an investigation,” Gold says.
 

For example, a physician performs a procedure in a patient’s abdomen and inadvertently nicks the patient’s bladder, requiring surgical repair. If there is documented severe adhesions and considerable time and difficulty spent by the physician in lysing the adhesions, the entry into bowel or bladder is unavoidable.

However, if there is no such documented difficulty, the event should be coded, since it can be construed that you’re trying to conceal the error, Perez says. Also, if the patient requires a longer length of stay, coding the complication provides evidence for the use of extra hospital and physician resources.

Assigning complication codes for a foreign body (i.e., a sponge) inadvertently left in a patient’s abdomen is another difficult matter that should be reported only under appropriate circumstances. If the count is incorrect and the surgeon reopens a few layers and retrieves the sponge before the conclusion of the procedure, there was no foreign body inadvertently left in, Gold says. Therefore, reporting a complication code is inappropriate. However, if the case required a return to the OR from the recovery room (PACU), re-prepping, draping, and re-anesthetization, it constitutes a reportable complication, he says.
 
“Physicians need to be made aware that the identification of conditions in the postoperative phase justify the patient’s severity, length of stay, and the resources,” Gold says. “But they are not always a complication nor are they all counted as complications. They are conditions the physician treats.”
 
In addition, in conjunction with a complication, a coder must also report an appropriate E code (external causes or effects), which are used for statistical reporting for risk management. “Facilities have been fined for not reporting these codes,” Perez says. “If you’re not doing that, you’re not providing good data quality from a statistical perspective.”
 
How ICD-9-CM codes affect HealthGrades, AHRQ scores
Complication codes affect physician profiles and hospital report cards on publicly available Web sites like HealthGrades (www.healthgrades.com) and the Agency for Healthcare Research and Quality (AHRQ). You can find a complete list of the codes used to determine the HealthGrades complication lists here.

Because this list is little known and distributed, confusion and miscommunication in many CDI and HIM/coding departments are rampant, Perez says. “Facilities aren’t getting these codes reported for fear that the physicians are angry, but you’re doing a disservice to your data and particularly for severity aggregate data that provides justification for length of stay and the cost of utilization of resources,” he says.

For example, after some recent changes in their algorithms, 285.1 is not one of the codes HealthGrades uses to determine complication rates, whereas 998.11 is—a common misconception. “People need to be aware of and do due diligence on the list, if they’re being told what is and isn’t a complication code,” Perez says.
 
Another problem with 285.1 is that the index of ICD-9-CM Manual defines it as Anemia, blood loss acute. But the tabular list defines it as “post-hemorrhagic anemia”—terminology that puts physicians on the defensive.
 
“[Post-hemorrhagic anemia] is what gets reported in the coding summary sheets, and the descriptor implies to the physicians that it’s a serious complication of surgery,” Perez says.
 
In many instances, instead of reporting a diagnosis as a complication of surgery, the CDI specialist should work with the physician to ensure that the condition is properly documented as present on admission (POA) when the evidence exists that it, indeed, was present on admission.
 
Tips to deal with reluctant surgeons
CDI specialists running into difficulty from surgeons and other physicians regarding documentation of complications should address the problem directly. Confront the issue head on by considering the following strategies:
 
1. Don’t be afraid to show them the complication codes. Physicians are very empirical and scientific oriented, Perez says, and will want to see the HealthGrades codes that are and are not considered complications.
 
2. Use a peer-to-peer approach and empower one of your physician leaders within your facility with the information, Perez suggests.
 
3. Address what is considered a complication in the coding world. A complication in the coding world is an adverse event which impacts the patient’s health in the postoperative period, and that is not integral to a procedure, Gold says. “It also requires resources above and beyond those expended on the ordinary patient,” he adds.
 
Nothing in this definition implies negligence. “The fact that the physician may have inadvertently nicked another organ while doing a surgery does not prove negligence until proven in a court of law,” Perez says.
 
Since there is little consensus in the larger medical community as to what constitutes a complication, Perez encourages hospitals to develop their own by-laws and parameters with input from their medical staff, as long as they do not conflict with ICD-9-CM Official Guidelines and Coding Clinic advice, he says. “This provides some consistency and standardization with the coding data within those facilities.”
 
4. Ask physicians to document when certain outcomes are expected events, not complications. “Always give [physicians] that option of whether the event preceded the surgery, or was integral to the disease,” Gold says. “It’s a matter of teaching the docs to better identify situations that existed prior to the patient going to the operating room, so that they can make sure they aren’t receiving inappropriate assignment of the 900-series codes.”
 
Teaching physicians to document when a condition already exists—be it respiratory failure, atelectasis, or urinary retention, for example—can help alleviate the problem.

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