Complications occurring years after procedure


I am just looking for some coding guidelines regarding complications of procedures that occur years after the procedure.

Example 2022 patient had mastectomy. January 2024 patient presents with abscess at site. I had an educational opportunity to send a query for complication of procedure. Query sent and complication code obtained.

is there a timeframe for complication codes?

If there is an infection and/or abscess at any surgical site years after procedure, do we automatically send a query to clarify if this was a complication to prior procedure?

Thank you for any guidance,

Beth Vorachek RN, MSN, CCDS


  • Beth that is a great attention to detail on your part. the guidelines related complications do not offer a time period constriction.

    Section 2B.16 states:

    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 the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.

    So the criteria would be what is stated above (No time constriction). your query to ensure the provider linked the abscess to the surgery and the associated documentation are all that is needed.

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