In this issue of CCS Prep! we will address the code assignment of postoperative complications. This tends to be a difficult area of coding. Documentation in the medical record plays a key role. The following represents some guidelines to follow in preparation for taking the CCS and CCS-P examinations.
1. Categories 996-999 of ICD-9-CM are used to report complications of medical and surgical care in many instances. One example is code 996.4, Complication of internal orthopedic device, implant or graft. However, ICD-9-CM also provides codes in other categories that address postoperative complications. An example of this is code 568.0, Postoperative gastrointestinal adhesions. Coders must follow and be guided by the entries within the ICD-9-CM Index to diseases in order to assign the correct code. The rule typically is to refer to a main term for the condition in the index and look for the sub term indicating "postoperative" or "complicating." An example is Adhesion(s) ... postoperative." If an entry is not under the main term, refer to the term "Complications" in the index.
2. The "Official Coding Guidelines for Coding and Reporting," developed and approved by the four cooperating parties, addresses complications of surgery and other medical care when it is a principal diagnosis. Guideline 2.15 states: "When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996-999 series, an additional code for the specific complication may be assigned." Many coders assign only the 996-999 code. However, it is correct to assign both the 996-999 code and the specific additional code to fully describe the condition in these cases. See Coding Clinic 1995 3rd Quarter, p. 5.
3. Conditions that occur following surgery are not necessarily classified as postoperative complications. Many conditions are an expected result or outcome of surgery. Consider the patient who experiences atelectasis following an open cholecystectomy. In many cases, this is an expected radiology finding or a condition that is self-limiting. In this instance, a code would not be assigned. If however, the physician documents atelectasis and the associated signs and symptoms such as fever, atelectasis' impact on the patient's stay and that the atelectasis is treated with respiratory therapy, then in this case, the postoperative codes 997.3 and 518.0 would be assigned. Refer to Coding Clinic 1990 4th Quarter, p. 25.
4. A coder cannot decide whether a condition is a postoperative complication from inference within the medical record. The cause and effect between the surgery and the condition occurring postoperatively must be documented within the medical record by the physician. For example, a two-point drop in hemoglobin and hematocrit after surgery in which 1200 cc of blood is lost does NOT constitute a postopera- tive complication. The physician must be queried as to the significance of this finding. The physician MUST document the diagnosis within the medical record including the type of anemia, if applicable. For example, the physician must document "acute blood loss anemia and significant intra-operative blood loss due to surgery" in order to assign codes 998.11 and 285.1. Do not depend upon a patient receiving treatments such as transfusions only to indicate a postoperative problem. Many times, postoperative transfusions are given routinely as a matter of prophylactic course without respect to complications of surgery.
5. When a postoperative complication is coded from the series 996-999, code also the specific condition as an additional code (i.e., postoperative urinary retention, 997.5 and 788.20), unless the index or tabular indicates that only the code from categories 996-999 should be assigned.
6. No time limit is defined for the assignment of postoperative complication codes. Postoperative conditions may occur during the hospitalization for surgery (a secondary code is assigned) or it may occur years after the initial surgery as a reason for the patient to seek care (it would be assigned as the principal diagnosis if it is the principal reason for admission of the patient to the hospital or for outpatient care).
7. Postoperative pain should be assigned to the code that describes the site of the pain rather than to series 996-999. Refer to Coding Clinic, 1993 #5, p. 8. "Coders should not assign other codes from the 996-999 series for postoperative pain unless the index specifically leads them to this code series."
8. Many times, postoperative or intra-operative complications are documented within the physician's progress notes. However, the coder should review all record documentation. For example, severe bleeding during surgery as a result of the procedure with correction may only be documented on the surgeon's operative report. In this case, the coder may miss this documentation if the entire operative report is not read.
9. Postoperative fever should not be coded based on clinical information within the record only. Body temperatures may vary following surgery, depending on the individual circumstances. The physician should always be queried about postoperative fevers to determine if there is a postoperative complication causing the fever. Sometimes, a fever is an expected outcome of the surgery, is not treated and is not coded. Always query the physician when in doubt about the documentation in the record. See Coding Clinic, 1994 5th Issue, page 7.
10. The term "complication" as used in ICD-9-CM does not imply that improper or inadequate care is responsible for the problem.
11. Complications of abortion, pregnancy, labor or delivery are reclassified in chapter 11 in ICD-9-CM. Please refer to this chapter when coding these types of complications as they take precedence over other code chapters.
12. Be attentive to the word "iatrogenic." This frequently implies that a condition is a result of treatment.
13. Be cautious in reading "status post" conditions within the medical record. This term usually indicates that a procedure was performed on the patient in the past. It does NOT imply a postoperative complication.
14. ICD-9-CM has a section devoted to complications due to presence of internal device, implant or graft. This is category 996. Please review this category prior to taking the examinations.
15. Review all Coding Clinic issues pertaining to postoperative complications, prior to taking the examinations.
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing contract coding and coding compliance review services for hospitals. The corporate office is headquartered in Pawley's Island, SC.