Health Information Management

Simplify coding, CDI concerns for complications

HIM-HIPAA Insider, March 9, 2015

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A complication basically refers to an unexpected result, outcome, or event. When it comes to coding complications in ICD-10-CM, coders should focus on the unexpected part.

The ICD-10-CM Official Guidelines for Coding and Reporting state that code assignments are based on the relationship between the care provided and the condition the patient has. That care includes any procedure performed.
It's not uncommon to see conditions arise in the postoperative period. The question is, are they all considered postoperative complications just because the patient underwent surgery during the admission? The answer is no, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. The patient may have had the condition anyway, regardless of whether he or she underwent surgery. "That's why the guidelines remind us that not all conditions that occur during or following a procedure are considered complications," McCall adds.
Remember that complications don't come with a time limit, says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro. "You could have had a hip implant put in 20 years ago, and now all of a sudden it could be malfunctioning or causing pain. The pain or malfunction could be a complication of that implant."
Continue reading "Simplify coding, CDI concerns for complications" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the March issue.

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