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Editor’s Note: See also coding complications training PowerPoint presentation in the Education & Training
section of the Forms & Tools Library.
Medical Record Information Services
Policies & Procedures
SUBJECT: Coding of Complications
EFFECTIVE DATE:
TITLE: Coding of Complications
REVISION DATES: 11/20/09
PAGE NO: 1 of 7
I.
PURPOSE: To provide guidelines for the selection and coding of complications. To
ensure minimal variation in coding practices and to achieve a high level of coding
accuracy, integrity, and quality. Also to provide communication to our physicians as to
how coding translates their medical documentation into complication codes.
II.
BACKGROUND:
A.
Proper capturing and reporting of complications is imperative to accurately
report the severity of illness and risk of mortality for our facility.
B.
The coding of complications is one of the more difficult coding challenges.
A coder must perform a thorough analysis of physician documentation to
determine:
1. If a condition is reportable;
2. If that condition should be considered as a complication;
3. If there is sufficient documentation to support the code; and
4. If there is a need to query the physician regarding the potential
existence of the complication
C.
An additional challenge is that these codes are used as part of systems analysis
to generate profiles for both physicians and facilities, yet codes alone do not
make any determination as to the outcome of care rendered nor do the codes
reflect severity or grading.
D.
Provider documentation that a condition resulted from a treatment / procedure
can be challenging due to the negative connotation that the term implies.
While ICD-9 does not suggest that use of the term indicates inadequate care,
many providers are reluctant to document some conditions due to third- party
analysis of coded data for quality initiatives.
This policy is intended to provide direction for the correct identification of
complications for both our coders and physicians.
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III.
DEFINITIONS:
A. Complication:
1. “A condition arising during the hospitalization that modifies the course
of the patient’s illness or the medical care required” (Huffman, HIM
Management.)
2. “A morbid process or event occurring during a disease that is not an
essential part of the disease, although it may result from it or from
independent causes” (Stedman’s)
3. “Complications as any deviation from the normal postoperative course,
such as arrhythmia and atelectases” (Annals Surgery)
B. Complications are coded as additional diagnoses:
1. UHDDS: All conditions that coexist at the time of admission, that
develop subsequently, or that affect the treatment received and/or the
length of stay. Diagnoses that relate to an earlier episode and have no
bearing on the current hospital stay are to be excluded.
2. Coding Clinic: Additional conditions that affect patient care in terms of
requiring:
a.
Clinical evaluation;
b.
Therapeutic treatment;
c.
Diagnostic procedures;
d.
Extended length of hospital stay; or
e.
Increased nursing care and/or monitoring
IV.
CODING INSTRUCTIONS:
A. General Instructions:
1. Portions of the record that contain acceptable physician documentation
to support code assignment include the following: diagnosis record,
discharge summary, history and physical, emergency room record,
physician progress notes, physician orders, physician consultations,
anesthesiologist notes, and operative report/notes. Codes for
diagnoses and procedures must be documented in the body of the
medical record by a physician directly participating in the care of the
patient. This documentation must be clear and consistent.
2. CPMC coders will query the attending physician for clarification if
required.
3. Query the physician if there is a discrepancy in the record regarding
diagnoses or procedures to be coded. Also, query the physician when
significant abnormal findings, diagnoses or procedures are
documented in other areas of the medical record, such as nursing
notes, respiratory therapy notes, radiology reports, pathology and
laboratory reports, EKG, nutritional evaluation, medication
administration, graphic record, and other ancillary reports. Any
suspected conditions must be documented by the attending physician.
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B. To consider a diagnosis a complication:
1. The condition is more than a routinely expected condition or
occurrence
2. There must be a cause and effect relationship documented between
care provided and the condition coded as a complication
3. Must be documented
4. For instance, the terms documented as ‘postoperative ileus or
‘postoperative atelectasis” are coded as complications. However, the
same terms listed only as ‘atelectasis’ or ‘ileus’ are NOT listed in the
coding classification system as complications
C. Care must be exercised to ‘err on the side of caution’- if it is not clear the
condition being considered is a complication, then do not code it as a
complication.
D. Do not assume an event, such as postoperative atrial fibrillation, should be coded
as a complication. Review the medical record carefully for all preexisting
conditions and be aware that the patient may experience an acute exacerbation of
a pre-existing condition or previously undisclosed or unknown medical condition
for a variety of reasons. This may or may not be directly related to medical /
surgical care. This logic will be applied to a multitude of other conditions, such
as a myocardial infarction, sepsis, acute renal failure, stroke, etc. These are only
coded as complications when the documentation clearly states the condition is a
complication.
E. For ambulatory surgery patients who are subsequently admitted to inpatient status
because of a complication, the principal diagnosis is the complication (reason for
admission), and the secondary diagnosis is the reason for the surgery.
F. Specific Instructions:
Incidental Serosal Tear: XXXX will not code as this as a complication,
unless the record explicitly states the tear is a complication. In this case,
this is coded as 998.2, Accidental Tear or Puncture:
Physician Perspective: Laceration of small or large intestine during
takedown of adhesions in patient who has had multiple previous surgeries
or abdominal irradiation or inflammatory disease when entering the belly
for intestinal obstruction due to those adhesions or for any other operative
procedure, such as cholecystectomy or colon resection, etc, may be only
incidental to the procedure, and should not be coded as a complication.
(AHA Coding Clinic for ICD-9-CM, 3Q 1990, Volume 7, Number 3,
Page 18)
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Question:
Should a tear during surgery be coded to 998.2? Operative report states
small tear of liver during retraction, controlled with hemopad.
When there are multiple adhesions present in the abdomen and they are
lysed with a statement of duodenal serosal tears postlysis, would code
998.2 be assigned?
Answer:
When a tear is documented in the operative report, such as a small tear of
liver during retraction, the surgeon should be queried as to whether the
small tear was an incidental occurrence inherent in the surgical procedure
or whether the tear should be considered by the physician to be a
complication of the procedure. Assign 998.2, Accidental puncture or
laceration during a procedure.
Coder’s Perspective: Coding Clinic states, “Any event, that results in need
to repair or re-operate because of unplanned entry into intestine, other
organ or major blood vessel, is a ‘complication’.”
Dural Tear: Tears of the Dura are always coded, but if the record does
not state the dural tear is a complication, the tear is coded as incidental349.31. A dural tear documented as a complication is coded as 998.2,
Intraoperative Tear/Laceration. (AHA Coding Clinic ® for ICD-9-CM, 4Q
2008, Volume 25, Number 4, Pages 109-110)
Effective October 1, 2008, new codes have been created for intraoperative
incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in
order to distinguish dural tears from other types of accidental surgical
lacerations. The dura mater covers the spinal cord and the spinal nerves. A
tear in the dura that occurs during spinal surgery is not unusual and is
typically repaired intra-operatively when identified. Primary closure of the
dural tear is usually accomplished. Dural tears that are not discovered
during surgery can result in leakage of cerebrospinal fluid (CSF), leading
to CSF headache, caudal displacement of the brain, subdural hematoma,
spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula.
As stated in Coding Clinic First Quarter 2006, page 15, “Dural tears are
coded, because a dural tear is always clinically significant due to the
potential for cerebrospinal fluid leakage.”
Ileus: XXX will only code this as a complication if the term
‘postoperative’ is used to describe the condition, or if the record
otherwise states the ileus is a complication. A short term ileus is expected
in the postoperative period for many patients. CPMC will not assume an
ileus stated as ‘following GI surgery’ is a complication.
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Ileus can have different relationships to the procedure and may not be
related to any procedure whatsoever:
 Exist before a procedure and unrelated
 Exist before a procedure and due to the disease
 Start after the procedure due to the disease
 Start after the procedure due to a complication that occurred during
the operation
An Ileus can be mechanical, as obstruction of the bowel, reflexic due to
inflammation or as response to handling, or due a current disease, such as
a neurologic or muscular dysfunction (diabetes, Ogilvie’s syndrome, etc.).
Documentation of postoperative ileus requires the assignment of a
complication code.
Example: Acute ruptured appendicitis with “postoperative ileus” (540.0
appendicitis), and postoperative ileus (997.4 – GI Complication) and 560.1
(Ileus)
The term Ileus is indexed as follows:
• Ileus (adynamic) (bowel) (colon) (inhibitory) (intestine) (neurogenic)
(paralytic) 560.1
• Ateriomesenteric duodenal 537.2
• Due to gallstone (in intestine) 560.31
• Duodenal, chronic 537.2
• Following gastrointestinal surgery 997.4
• Gallstone 560.31
• Mechanical (see also obstruction, intestine) 560.9
• Meconium 777.1
• Due to cystic fibrosis 277.01
• Myxedema 564.69
• Postoperative 997.4
• Transitory, newborn 777.4
Atelectasis: This condition is often only incidental, and should not always
be coded. However, if it satisfies the UHDDS Definition of a Reportable
Condition, it should be coded. However, it is coded as a complication
only if the record states that the atelectasis is a complication or describes
this as ‘postoperative atelectasis’. (AHA, Coding Clinic ® for ICD-9-CM,
4Q 1990, Volume 7, Number 4, Page 25)
Question: Is atelectasis following surgery always considered a
postoperative complication?
Answer: Postoperative atelectasis is often an incidental radiographic or
physical finding that is frequently a self-limiting condition, in which case
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it would not be coded or reported. If, however, it is associated with
significant findings, such as fever, or requires further diagnostic or
therapeutic work up, such as chest x-ray or respiratory therapy, or is linked
to an extended hospital stay, then it should be reported as 997.3,
postoperative respiratory complication.
V.
POLICY:
XXX, Medical Record Information Services Coding policy adheres to standard polices
published in “Coding Clinic”.
VI.
SCOPE:
This policy applies to Hospital Coding including Inpatient acute, Psychiatry, SNF, Acute
Physical Rehabilitation, Emergency Department, and Ambulatory Surgery.
VII.
OVERSIGHT:
The Coding Manager will oversee the appropriate reporting and collection of hospital
discharge data.
VIII.
EDUCATION AND TRAINING:
Upon employment, each coder will be provided with a copy of this policy. Training on
Policy & Procedure (P&P) for this data element will be provided by the supervisor.
VIIII. AUDITING AND MONITORING:
X.
A.
Adherence to this policy will be reviewed with each coder as part of his/her
annual evaluation.
B.
Coding Manager will evaluate and monitor compliance with this policy as part of
regular, ongoing quality of coding review.
PROBLEM IDENTIFICATION:
A.
Coding Manager will review findings on assessment of each coder’s accuracy on
reporting data. Coder’s should be advised of problems identified with follow-up
training provided.
B.
Manager will report findings on data errors to the coder’s at the completion of
data corrections. If any error trends are identified, supervisor will develop and
distribute additional education and or training to coders.
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XI.
ENFORCEMENT:
Coder who is non-compliant is subject to employee corrective disciplinary action.
Responsible for Policy:


Coder, Health Information Management
Responsibility for ensuring these guidelines are met rests with the Coding Manager of Health
Information Management
Author:
Paul Evans, RHIA, CCS, CCS-P
Coding Data Coordinator
Approved by:
Approved Date:
October 2009
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