How to Code Complications
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By Valerie Fernandez, MBA, CPC, CPC-H, AHIMA ICD-10 Trainer
Complications are an unfortunate outcome for some patients who receive medical treatment. This article provides an overview of how to properly determine and code complications.
The provider documentation is what drives code assignment. For surgical procedures, there should be a relationship between the procedure performed and the diagnosis. According to coding guidelines, not all conditions that arise following medical or surgical care are complications. There should be a cause-and-effect relationship between the care provided and the condition. Any documentation that is unclear or incomplete requires a query to the provider for clarification and an update to the documentation. There is no time limit assigned to the development of a complication; patients can experience complications during the hospitalization, immediately afterward, or a long time after the hospitalization.
In order to assign a complication code, there are a few things to consider. If something unexpected or unusual occurs during or after the provision of care, it is appropriate to assign a complication code. There must also be a relationship that clarifies a cause and effect, and documentation should indicate that a complication occurred. In assigning codes related to complications of care, the coder should utilize all references. This includes any electronic coding software as well as code books and coding reference material. In ICD-10 it is important to use all guidance offered related to a particular diagnosis, which would include the "includes" and "excludes" notes.
ICD-10 offers an expanded selection of complication codes. Each body system provides intraoperative and postprocedural complications. There are also complication codes related to transplanted organs and tissues. Complication codes are only assigned for transplanted organs if the function of the transplant is impacted. Two codes are required to fully describe transplant complications. They include the complication of transplanted organ and the specific complication. A preexisting condition that was present prior to the transplant can be coded as a complication if it impacts the function of the transplanted organ. Additionally, complication codes exist related to infusion, transfusion, and injections. Prosthetic devices, implants, and grafts have specific complication codes as well. The coder must also consider postprocedural shock, postprocedural infection, and wound dehiscence codes.
Coders should seek clarification before assigning iatrogenic codes, which means "caused by the physician." An interesting example relates to a planned implant break. This scenario was provided by the American Hospital Association Coding Clinic in the second quarter of 2015. A patient had a displaced comminuted fracture of the right tibial shaft after a fall from 30 feet. During the open reduction, internal fixation was used to secure the bone to permit healing. Subsequent to the routine healing, the screws in the internal fixation became loose and the patient was scheduled for removal of the internal fixation. This is not a complication of the open reduction but rather a planned or expected outcome. As the bone heals, the patient becomes more mobile through physical therapy. As weight bearing is increased, the screws loosen and require removal. Therefore, a subsequent code of S82.251D for displaced comminuted fracture of the shaft of the right tibia subsequent encounter for closed fracture with routine healing would be assigned along with an external cause related to the injury, which is W17.89XD for a fall from one level to another subsequent encounter.
Operative reports may often contain documentation regarding a laceration, yet no documentation regarding a complication. A query is necessary for clarification before assigning a complication code. Further, inquiries need to be timely and documentation updates need to be handled expeditiously prior to claim submission. Robust documentation along with robust coding will withstand scrutiny by external auditors and can be supported for any appeal on the account.
To justify coding a complication, it must be clinically evaluated, diagnostically tested, and therapeutically treated. According to a recent HCPro newsletter, the complication must also result in an extended length of stay in the hospital necessitating increased resources related to care. The condition should not be part of routine care or the routine outcome of an expected procedure. Even if the physician discusses potential outcomes prior to the surgery, it is important for the coder to seek clarification from the doctor before assigning a complication code. The physician must agree and must document that the condition is a complication.
Key elements to include in queries are clinical indicators, positive findings, the physical exam, treatment provided, and an assessment regarding the documentation and whether information is missing or unclear. Frequency and acuity are important determinants, as are assessment of whether a condition presents with or without an infection. Devices must be specific in order to assign a code, and complications related to devices must be addressed via query as needed. Further, nonspecific procedures need to be clarified. Assessments also need to be made related to complications associated with trauma.
Pain related to implants or prosthetic devices fall into the category of a complication. An example is T85.84XA, which is pain due to internal prosthetic devices, initial encounter. Additional codes are then required to identify the type of pain and the specifics related to the condition.
If physician progress notes document postoperative fever, that is coded to a complication code. However, if the physician only documents fever in the postoperative period, a query is needed to clarify whether this was a complication of the procedure. It is important to report secondary diagnosis codes to demonstrate the severity of the condition and to support any additional resources required in the care of the patient.
Many orthopedic procedures result in blood loss, as there is cutting into the bone. This is expected during the operative procedure. For knee replacements, the bleeding occurs after the procedure and is also an expected outcome of this procedure. It is only if the patient becomes symptomatic and requires a transfusion that acute blood loss anemia, D62, would be added to the claim as a secondary diagnosis.
It should be noted that it is important to ensure accuracy when reporting complications, as these codes have the potential to adversely impact the value-based performance and quality metrics, which may result in decreased reimbursement and possible recoupments. Complication codes must be validated prior to claim submission.
Valerie Fernandez is the assistant director of health information management, and previously the ICD-10 quality assurance manager at the Hospital for Special Surgery in New York. She also holds a CPC and CPC-H from the American Academy of Professional Coders (AAPC). She served as president of the midtown Manhattan chapter and president for the Manhattan chapter of the AAPC.