From ICD-9 Guidelines: 18. Documentation of Complications of care Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.
Seems to me that "s/p" does not clearly document a cause and effect relationship. Could just as easily indicate a temporal relationship. I'd suggest query to confirm.
Agreed. I don’t think 'S/P' always signifies a cause/effect relationship, similar to 'Post-op'. I'd query. Luckily, this is now simpler because the new query brief allows a simple yes/no query for cases like this.
Katy Good, RN, BSN, CCDS, CCS Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Cell: 928.814.9404
Comments
18. Documentation of Complications of care
Code assignment is based on the provider’s documentation of the
relationship between the condition and the care or procedure. The
guideline extends to any complications of care, regardless of the
chapter the code is located in. It is important to note that not all
conditions that occur during or following medical care or surgery are
classified as complications. There must be a cause-and-effect
relationship between the care provided and the condition, and an
indication in the documentation that it is a complication. Query the
provider for clarification, if the complication is not clearly
documented.
Seems to me that "s/p" does not clearly document a cause and effect
relationship. Could just as easily indicate a temporal relationship.
I'd suggest query to confirm.
Don
===============
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404