The introduction of ICD-10 brought extensive changes to healthcare coding including the introduction of thousands of new codes, many of which providers are still getting comfortable with. One area that providers have found particularly challenging is the coding of medical complications. Although ICD-10 has made it easier to code complications through the elimination of separate complications codes and the separation of intraoperative and postoperative complications, questions still arise. At times, it can be difficult to determine if a complication is in fact a “postoperative complication” or if it is an expected outcome from a certain procedure or disease. Furthermore, as a provider, you may be hesitant to document postoperative complications for risk of negative feedback and/or ratings.
Most Common ComplicationsNaturally there are numerous complications that can arise following a medical procedure. However, the most common complications below have been the cause for many debates between physicians and medical coders. Debates arise as to whether the conditions following surgery are expected outcomes or in fact postoperative complications. The most common complications include:
- Postoperative Shock
- Postoperative Atelectasis
- Postoperative Atrial Fibrillation
- Postoperative Paralytic Ileus
When To Code ComplicationsIf you find yourself questioning a complication code, first ask yourself if the following 4 questions. If the 4 items below are true, then a complication code should be used. The conditions are as follows:
- Did the physician document that the condition is a complication?
- Was the condition an unexpected outcome or occurrence from surgery and/or a pre existing condition?
- Is there evidence that the physician evaluated, monitored, and treated the condition?
- Is there a cause-and-effect relationship between the condition and the procedure performed and/or care given?
Tips for Coding Medical ComplicationsBelow are a few helpful tips to refer to when coding medical complications.
- Remember that not all conditions that occur following a procedure at complications.Look for a cause-and-effect relationship between the procedure and the condition.
- Ask yourself if the outcome is unexpected or “rare”.
- Speak to the physician directly to clear up any questions.
- Complications can arise at any time, including hours, days, months, or even years following a procedure.
- Look for the presence of words such as “iatrogenic”, “due to”, “resulted from”, etc. in physician notes.