Health Information Management

Tip: Use 3rd Quarter Coding Clinic to help resolve surgery complication questions

CDI Strategies, November 26, 2009

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The American Hospital Association’s Coding Clinic for ICD-9-CM contains official advice from the ICD-9-CM cooperating parties as to how coders and CDI specialists must interpret and code submitted clinical scenarios. In the first of a quarterly series of special reports available to ACDIS members, James S. Kennedy, MD, CCS, director of FTI Healthcare in Atlanta, looks at the highlights from the third quarter 2009 issue as they relate to CDI.
Complications of surgery were one of the primary concerns illustrated in the October special report. Dissection of iliac artery (Coding Clinic, p. 3) and postoperative hyperglycemia (Coding Clinic, p. 5) both provide important insights into complications of surgery, specifically whether an event during or after surgery should be reported as a complication.
In the entry on p. 3, the physician documented a dissection of the iliac artery during the course of an angioplasty and stent placement. The dissection was only within the lesion undergoing the angioplasty, after which a stent was deployed. The proceduralist’s last note indicated that the “patient tolerated the procedure well without any complications. Successful angioplasty and stenting of right external iliac.” Coding Clinic advises not to assign a code for the dissection in this case because the physician did not document its clinical significance nor did he document that the dissection was a complication. Specific to angioplasty, Coding Clinic emphasizes that:
“…when the dissection extends further than anticipated, leading to an occlusion, or is responsible for additional procedures and/or other complications, it is clinically significant in such cases and it would be coded and reported.”
In essence, CDI specialists and coders are directed that localized dissections are integral to angioplasty and should not be coded unless otherwise indicated.
ACDIS members can download the special report Coding Clinic Update, or by visiting the Web site and clicking on CDI Journal on the left bar.

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