The Term "post-op"

Example: MD writes postop ileus on POD2 after abdominal surgery. Bowel function returns by day 4 and pt is dc'd home. Do you still query asking if the ileus is a complication because they used the word "postop". Or do you just ignore since it is inherent to surgery? I wouldn't code ileus normally in these circumstances but I'm concerned re the use of "post op"

Another example- post op atelectasis; common finding after surgery.

Post op hypotension- do you ask if its a complication?


  • The term 'post op' is a period of time. There is no linkage to a complication, therefore one would not be coded, nor queried as there is no documentation showing it required additional care, etc. See Optum360's Guide to Clinical Validation which may help you.
  • We see several scenarios when "post op" refers to "after the surgery" i.e. from a timeline/ chronology perspective. However in the coding world, it gets interpreted as "due to" the surgery i.e. complication. Would like to know the industry-wide norm (overall) to manage this. Thanks! 
  • The term postoperative does not universally get interpreted in the coding world as a complication...the decision of how and when to code a complication is far from being that simple.

    Paul Evans, RHIA, CCDS
  • There are very detailed references available regarding the complexities of ‘querying’ for complications and coding of same.  It really can’t be covered in this forum due to the complexity.  There are resources on this webpage covering this topic in great detail that are very useful.

    Paul Evans, RHIA, CCDS
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