Health Information Management

Coding postop or post-traumatic infections with OR procedures

HIM-HIPAA Insider, April 13, 2010

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RACs already are validating countless MS-DRGs in hospitals nationwide, and the number of eligible targets continues to grow. Coders should keep a watchful eye on these three MS-DGRs, which are among the list of approved audit issues for multiple RACs:

  • 856 (postop or post-traumatic infection with operating room [OR] procedure with MCC)
  • 857 (postop or post-traumatic infection with OR procedure with CC)
  • 858 (postop 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. Take the time to 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 postop seroma)
  • 998.59 (other postop 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 that a patient truly has apostoperative 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 postop fever, but this doesn’t necessarily mean coders should report 998.59. If the fever isn’t associated with a known infection, report 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 998.51 could yield one of the previously listed MS-DRGs whereas reporting 998.12 (hematoma complicating a procedure) would not.
Editor’s note: For additional tips, see the April issue of Briefings on Coding Compliance Strategies.

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