Health Information Management

Ensure accurate coding for postoperative conditions

JustCoding News: Inpatient, September 26, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Patients aren’t the only ones paying attention to quality scores these days. Payers are, too.

How are these quality scores derived? Various entities profile hospitals and physicians based on length of stay, severity of illness, risk of mortality, and cost. These profiles help to ensure that the care provided is appropriate and consistent with similar providers in a particular geographic area.
“Postoperative complications are very frequently used as one of the stronger indicators that [profiling entities] feel represent how well the hospital cares for its patients,” said Cheryl Manchenton, RN, BSN, senior inpatient consultant with 3M Consulting during the July 12 HCPro audio conference “Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding Concerns.”
Reviewing the coding guidelines
Physician and hospital profiles include rates for certain complication-related ICD-9-CM codes, such as those in the 996-999 series. However, profiles also include rates for non-complication codes, such as atelectasis, pleural effusion, or UTI, said Manchenton.
Coding guidelines state that when a patient is admitted for a complication resulting from medical or surgical care, coders must report the complication code as the principal diagnosis. They should report a code for the specific condition as a secondary diagnosis.
Coders may also report an additional complication code when that code adds further specificity to the complication, said Audrey G. Howard, RHIA, senior inpatient consultant with 3M Consulting, who also spoke during the audio conference. Documentation must reflect with specificity, she added.
Coding Clinic reminds coders that a postoperative condition is not necessarily a postoperative complication. That is an important distinction, said Howard. Postoperative complications must meet all of the following requirements:
  • The condition cannot be routinely expected after a procedure.
  • The condition must be clearly linked to the procedure (i.e., the physician must document a cause-and-effect relationship).
  • The physician must document that the condition is a complication.
“Typically, the third item is the one that poses the most problems,” said Howard. “No physician likes to indicate the presence of a complication.”
Once identified as such, coders can only report the complication when it:
  • Persists beyond the expected time frame
  • Receives direct treatment
  • Extends the patient’s length of stay
Physicians may fail to document the clinical significance of a complication. For example, an operative note might include documentation of an accidental laceration. The surgeon documents that he or she asked a second surgeon to look at the laceration intraoperatively.
The note demonstrates the clinical significance of the condition, and the clinical documentation improvement (CDI) specialist or coder should query the physician to determine whether the condition is indeed a complication. Only a physician can determine whether a condition is a complication or an expected outcome. If the documentation is unclear as to whether a condition is a complication, coders or CDI specialists must query the physician.
“This guideline extends for any condition, even if it is not considered a complication,” said Howard.
Understanding HACs and PSIs
Profiling entities also monitor the frequency at which hospitals and providers assign codes for hospital acquired conditions (HAC) as well as conditions listed as patient safety indicators (PSI). HACs and PSIs negatively affect profiles. HACs may also negatively affect reimbursement. Medicare will withhold payment if an HAC occurs after a surgical procedure, and no other CCs or MCCs are reported, said Manchenton.
Not all conditions on the HAC list apply to the postoperative setting. However, the following conditions do apply:  
  • Foreign object retained after surgery
  • Air embolism
  • Blood incompatibility
  • Catheter-associated urinary tract infection (UTI)
  • Vascular catheter-associated infection
  • Surgery site infection following certain orthopedic procedures
  • Surgery site infection following bariatric surgery for obesity
“In terms of clinical documentation programs or physician queries, this is a nice hit list for your team to be reviewing,” said Manchenton. She says CDI specialists or coders can use this list as a reminder when reviewing charts to ensure that documentation justifies code assignment.
PSIs are sometimes reported publicly. “I have several clients that I work with whose [PSI] scores were published in the newspaper,” said Manchenton. “It was quite embarrassing for them.”
If diagnoses aren’t accurately documented or coded, these rates could portray an inaccurate picture to the public, she added.  
Using ‘postoperative’ correctly
Physicians don’t document the term postoperative consistently. Some physicians may simply use it as a timestamp to indicate when a condition occurs.
According to coding guidelines, coders should code conditions as complications when physicians document them as postoperative. However, if a coder or CDI specialist believes that the physician didn’t intend to link the condition to the surgery, then he or she should query for clarification.
For example, a patient undergoes a hip surgery. Three days after the surgery, the patient develops atrial fibrillation and requires treatment with Lanoxin®. The patient discloses to the physician that he has a history of heart palpation spells, and the physician documents this information in the record.
In this case, the atrial fibrillation is not a complication of the hip surgery. If the physician documents postoperative atrial fibrillation, coders should query to clarify whether the physician intended to link the atrial fibrillation to the procedure.
Overcoming challenges
Coders and CDI specialists must understand which conditions affect provider profiles. They must also take special care to avoid unnecessary queries, said Manchenton.
Likewise, physicians must understand how inaccurate coding of postoperative complications can negatively affect profiles. It’s especially important for physicians to understand the coding implications of the term postoperative.  
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Most Popular