Queries regarding surgical complications- when it isn't...

mamrncm@aol.commamrncm@aol.com
in CDI Management

Does anyone have a good template or sample for when a diagnosis is documented as "postop" and is going to be coded as a complication but shouldn't be?

we use a standard template with verbiage of

Is this an expected finding after a procedure?


then we enter what is documented - then the clinical indicators found- and then give the providers options - validating surgical complication, or expected due to: X, unavoidable due to X, other ( please specify) , unable to determine. Wondering if there is a better way to ask-

thanks in advance

Comments

  • KBecker@skagitregionalhealth.orgKBecker@skagitregionalhealth.org


    __ This was a complication of the procedure

    __ This was an incidental occurrence inherent to the procedure

    __ This was a complication but not due to the surgery (please specify cause):

    __ This was likely related to a pre-operative comorbidity (please specify cause):

    __ Other (please specify):

    __ Unable to determine (please comment):



    These are the options we use in our template for the provider to choose from----- of course we provide the documentation needing clarification, clinical indicators to support the query, procedure completed...etc


    Hope this helps!

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