Postop Complications
I understand the guidelines stating that the provider must link the condition (cause/effect) to the complication. However, it can be difficult to know when a query is needed for "postop" conditions as complications. Some conditions seem to be an obvious complication and others will require a query. Would the documentation noted below, without further specification, code to a complication code or need a query?
-Patient is s/p split thickness skin graft. The surgeon documented "s/p stsg, 98% graft loss".
-Patient is s/p bowel resection. The surgeon documented "POD 6, prolonged ileus" or "POD 6, significant ileus".
-Patient is s/p recent surgery, the hematoma is at the surgical site. Surgeon documented "postop hematoma".
-Patient is s/p recent abdominal surgery. Documentation shows, "recent abdominal surgery, intra-abdominal abscess".
-Patient is s/p recent abdominal surgery. Documentation shows, "abdominal incision open and draining".
Thank you!
Rae
Comments
1. Skin graft - This one is tricky because it's a "loss" of the graft but you need more information (was it failure, infection, rejection, etc?). I would probably query this one and ask him to identify the reason for the loss if known and use a multiple choice query with those options for him to pick from.
2. Postop Ileus - in the encoder you have a choice of "complication" or not even when selecting postoperative. If you don't select it you end up with Ileus, Unspecified K567. I would query to confirm it's a surgical complication as you have the potential to add a second postop code (ex K9189) if it is a complication of surgery in addition to the ileus code.
3. Postop hematoma - no query needed he's attributing it to the surgery.
4. Intra-abdominal abscess - I would query as he didn't link the abscess to the surgery.
5. Abdominal incision open - assuming he's referring to the surgical incision I'd code the dehiscence of operative wound and not query.
Erik Kilbo, CCS, CPC-I, CCDS, CDIP
Thank you!
I would also query to see if the post op hematoma is a complication of the procedure. A hematoma post heart cath at the insertion site is not uncommon. If not further treated or evaluated, we always query. We are in the habit of always asking unless the provider specifically says the "post op" occurrence is a complication.
16. 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, unless otherwise instructed by the classification. 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.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 18 of 117
This is our query template:
( ) The above is an inherent, integral or routinely potential/expected occurrence of surgery (not a complication)
( ) The above was an inadvertent, unintended, iatrogenic, or unexpected occurrence of surgery (complication)
( ) The above is a complication but not due to the surgery, specify cause:
( ) Other, please specify:
( ) Clinically unable to determine
!) Receive clinical evaluation
2) Result in additional diagnostic tests
3) Require additional treatment
4) Require additional nursing services
5) Result in a longer length of stay
Then the condition isn't even reportable under the UHDDS.
My apology, the statement isn't very clear... lol. If not treated, we would indicate that in the query sent hoping for the "not a complication" answer. Since so many of these are attached to PSIs, we try to make sure the documentation is crystal clear for the auditors who are awaiting the opportunity to pounce.