Query for postop complication
My scenario is this:
Per H&P and this is also stated on OP note patient returns for routine followup, now 1 weeks out from surgery. He has been avoiding active shoulder use and avoiding any lifting with His arm. He presents for an add-on visit after developing bloody drainage along the middle of the incision over the last 2 days.
PHYSICAL EXAMINATION: Physical examination today of the left shoulder shows a well-healing deltopectoral incision, but with a small area of bloody drainage along the middle of the incision. There is no erythema. There is some associated ecchymosis consistent with hematoma. The right upper extremity is otherwise grossly neurovascularly intact to testing. Plan If there is drainage persists or increases over the next day or two, we will likely plan for decompression of his hematoma.
The drainage persists so patient came in:
Per op Note: 07/21 Left shoulder draining hematoma. Status post left reverse total shoulder arthroplasty by myself on July 10, 2018. Here for Left shoulder open and irrigation with hematoma decompression.
The MD only documents postop hematoma. The CDI team believes that we cannot query the MD to determine if this was incidental to procedure or complication they cite we dont have clinical indicators. Please advice. I am not understanding how we do not have clinical indicators in this case.
Thanks
Comments
Interested if others feel same way.
Thanks,
Jeff
I agree with Jeff. You have all you need to query and I wouldn't assume its a complication due to the surgery.
Query options:
Is an expected occurrence and is not a complication
Is not an expected occurrence and not a complication
Is a complication but not due to the surgery/procedure - Specify cause:
Is a complication
Other (specify)
Unable to determine
Outside of trauma surgery, I don't know if post op hematomas are ever really "expected"? (Not sure if i would include that on the query unless it was an appropriate option) but the coders position and the coding guideline that this should always be reported as a post-operative complication is completely false.
There are dozens of scenarios where one could get a hematoma at the site of the surgery and it have nothing to do with the procedure itself such as:
1) Patient could have fallen on the location and the hematoma is as much traumatic as anything else.
2) Patient could have had a pre-existing issue with clotting times and hematomas and bruising
3) Patient could have been non-compliant with post op regimen and or medications, leading to increased risk for hematoma ANYWHERE on the body and just happened to (of course) get one at the surgical site
Okay maybe not "dozens" but certainly several.
The coders insistence that this should "always" be a post-op complication simply based on the available ICD 10 indexing is frankly, why there is often criticisms hurled at the coding profession from the RN community because the argument that "hematoma is 100% always a complication" is silly if you really think about it. I will concede however that the hematoma is highly likely to be a result of the surgery and the indexing probably does work the clear majority of the time.... I still cringe at the blanket statement made by the coder here. On the other hand, if there is nothing in the record to indicate an ALTERNATE cause of the hematoma, then the assumed relationship is likely the correct one. There really is no such thing as an "incidental post-op hematoma, unrelated to the surgery" in either ICD 10 coding or under any clinical definition I am aware of. If someone has links to any idiopathic post-op hematoma literature please post, I would love to read about it.
Agree w/ Allen that one should not blindly follow the index in regards to assignment of codes for 'complications'. Nor should we assume that a temporal relationship 'always' means that a complication surely exists. The factors leading to true complications is 'complicated' and all must use reasoning and logic.
Paul Evans, RHIA, CCDS
Unfortunately, the industry does not respect professional coders. I have 238 credit hours and several degrees and certifications...hurrah for me, right? What is pertinent is that if or when I work as a coder, my pay is pathetic.
I have to wonder why bright and educated folks would want to obtain a B.S. with the Clinical acumen to think deeply and code wih precision. The pressures on a coder to produce are severe...a coder is supposed to assmilate all manner of imprecise and conflicting Documentation, apply coding rules that can be confusing, and then submit a bill that is audit proof. The abstraction process, alone, for the coding function is considerable. Coding mgrs want bills dropped in a hurry with too much emphasis on production and not enough on quality.
I have been contacted by recuriters for ‘hot’ coding jobs in Oregon and Florida paying $20.00 per hour! Wow...really!
A chain in the NE just fired 400 coders, replacing them with overseas coders working remotely. The reason: $$
Until such time that the industry appreciates, and pays for professional and strong coders, this will not change. I have worked as both a professional coder and now as a CDI. The coding role is MUCH more difficult, frustrating, and misunderstood.
If , as a CDI, you work with a truly informed, educated and capable coder, they can be your best partner or your worst enemy.
My bottom line? I would not recommend the coding profession to a person giving that profession consideration. I do not regret the time and effort I spent to become and RHIA, but the profession is not appreciated, and sometimes unjustly denigrated. It gets old.
Paul Evans, RHIA, CCDS, CCS, CCS-P
I'm a bit late coming to the party, but here is more support for you in the future...
Let them know there is no 'presumption' when it comes to complications of care coding. There are very clear and succinct rules regarding code assignment for complications of care. I think both the coding educator and the CDIS need to read I.B.16 in its entirety, which continues on to state, "...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." (italics and bold font added for emphasis)
I would also point out that non-adherence to the Official Guidelines for Coding and Reporting (OGCR) is not advised. As stated in the OGCR introduction, "...Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)."
Another point that they the coding educator and CDIS seem to be confused over...if there are no clinical indicators to query (per them), then that logic also states there are no clinical indicators to support concurrent clinical validation and assign a code.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Karen As always, great information.
For clarification (and I misread it the first time also)...in this situation it was the Coder who knew the guideline and did not want to follow the index and it was the CDI who insisted that this be a complication (probably to get a CC)....thus my edit above.
If CDI are now doing this they are seriously misinformed as to the issues involved with regards to inappropriately reporting complication where none exists and the negative consequences to the facility for such a practice.