Health Information Management

Q&A: Documentation and coding for post-operative complications related to COPD

CDI Strategies, July 19, 2012

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Q: We recently had a case where a patient with severe chronic obstructive pulmonary disease (COPD) was admitted for several lung lesions. The patient went to surgery for de-cortication of lung due to left lung entrapment with adhesions, deep wedge resection of mass of the upper lung and left lower lobe, as well as closure of thorax fistula.

Two days after surgery, the patient was noted to desat. The chest tube was discontinued to suction. Because the patient had “subcutaneous emphysema after walking,” the patient went back to surgery for a pneumonolysis of the entire remaining lung. Final diagnosis stated “significant air leak/pneumothorax” and “subcutaneous emphysema post-op day three.” 

Should this be coded as a postoperative complication? Is the documentation supportive enough to link the condition to the surgery?

A: I do not think the documentation is supportive enough to code this as postoperative complication. Of course, you can query for clarification, but based on existing documentation, I would assign codes 512.84 and 518.1.
The patient already had an existing fistula tract prior to the original surgery. The first surgery was insufficient to do a full repair so the surgeons had to perform additional surgery to achieve the intended effect. The conditions the patient acquired after the original surgery are very common and expected due to her significant bullous lung disease.

Editor’s Note: This question was answered by Audrey G. Howard, RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer and Cheryl M. Manchenton, RN, BSN, during the July 12 audio conference “Inpatient Postoperative Complications: Resolve Your Facility's Documentation and Coding Concerns.”

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