March 25, 2016

Postoperative Complications: It’s complicated

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Complication coding is a hot topic among coding, clinical, and compliance professionals. It’s considered to be one of the more challenging aspects of coding. Physicians are hesitant to document post-operative complications, as they negatively affect their quality scores on sites like Healthgrades.com. Hospitals, however, need to be compensated for the extra resources and care provided when such a condition arises. That is why clinical documentation improvement (CDI) specialists need to work with providers to determine whether a complication is truly a “post-operative complication” or an expected outcome of the procedure or disease process.

For a condition to be considered a complication, all of the following must be true: 

  • It must be more than an expected outcome or occurrence and show evidence that the provider evaluated, monitored, and treated the condition.
  • There must be a cause-and-effect relationship between the care given and the condition.
  • The physician must document that the condition is a complication.

ICD-10-CM has made it easier to code complications by eliminating the separate complication (996-999) from ICD-9-CM and incorporating intraoperative and post-procedural complications into the separate body systems.

There are numerous complications that can occur in the post-operative setting. Let’s look at some of the most common conditions that can occur in the post-operative phase, many of which are causing tug-of-wars among physicians, CDI specialists, and coders – whether they are expected outcomes or post-operative complications.

Post-Operative Paralytic Ileus

This issue is probably one of the most common conditions seen following abdominal surgery – but is it a complication? Generally, a post-operative paralytic ileus that is present for up to three days post-procedure is considered by many surgeons to be an expected outcome of the procedure. An expected outcome is not coded as a complication. This would be coded: Ileus > Postoperative intestinal obstruction. The ICD-10-CM code used would be K91.3 (post-procedural intestinal obstruction).   

On the other hand, if the patient is not experiencing a return of normal bowel function after three days and is receiving treatment for the ileus (nasogastric tube, rectal tube, NPO status, reducing opioid pain medication, etc.), this is likely a complication and the physician should be queried for clarification. If the physician concurs that the ileus is a complication, it would be coded: Complication (from) > Post-operative > Digestive > Other. The ICD-10-CM code used would be K91.89 (other post-procedural complications and disorders of the digestive system), with an additional code to further specify the type of ileus. The paralytic ileus would be coded K56.0. 

Post-Operative Atrial Fibrillation 

Determining whether or not to view post-operative atrial fibrillation as a complication has several defining factors. First, does the patient have a history of atrial fibrillation that is currently being treated? If so, then post-operative atrial fibrillation is not a complication of surgery and was present on admission. Next, if a patient develops atrial fibrillation post-operatively, what was the outcome? If the patient had several beats of atrial fibrillation noted on cardiac monitoring that resolved on its own without treatment, this should not be considered a complication. On the other hand, if the post-operative atrial fibrillation required treatment, either with medications or defibrillation, this condition should be considered a complication. 

One area that varies among physicians is post-operative atrial fibrillation following cardiac surgery. Some will agree that it is a complication, while others will say it is an expected outcome of the cardiac procedure. In these instances, the provider should be queried for clarification that the post-operative atrial fibrillation was, in fact, a complication. ICD-9-CM coding allowed for post-operative atrial fibrillation to be coded as a complication, with supporting language in the Coding Clinic published for the fourth quarter of 2013. This guidance is not so in ICD-10-CM. The physician has to specifically document that the post-operative atrial fibrillation is a complication of the procedure. Let’s assume documentation of post-operative paroxysmal atrial fibrillation. This would code: Fibrillation > atrial > paroxysmal. The ICD-10-CM code would be I48.0 (paroxysmal atrial fibrillation). Now, let’s assume that the provider documented that the “post-operative course is complicated by paroxysmal atrial fibrillation requiring amiodarone drip.” This would code: Fibrillation > atrial > postoperative complication > paroxysmal. ICD-10-CM codes would be I97.89 (other post-procedural complications and disorders of the circulatory system, not elsewhere classified) and I48.0 (paroxysmal atrial fibrillation) based on the instructional note to use an additional code to specify the disorder.

Postoperative Atelectasis

Postoperative atelectasis occurs to some degree in many patients undergoing upper abdominal or thoracic surgery, but can occur in any patient who receives general anesthesia. It is an incomplete expansion of the lung segments that may result in partial or complete collapse of the lung. Atelectasis is an expected condition that occurs within the first 48 hours postoperatively. It is usually an incidental finding on chest x-rays and resolves spontaneously without treatment. ***** The patient is usually ambulatory, using incentive spirometry that is routinely a postoperative order and has no clinical symptoms. In this case, the condition is not a comorbidity or complication and should not be reported.  See Coding Clinic, Fourth Quarter 1990, pg. 25.

So, when is postoperative atelectasis a complication? On postoperative day 3, the patient is complaining of dyspnea and chest pain. Lab work shows WBC of 15. Physical exam reveals course lung sounds and heart rate of 100. Repeat chest x-ray shows no resolution of the atelectasis and pneumonia is ruled out. The patient is ordered albuterol nebulizer treatment every 4 hours and prn and is encouraged to use incentive spirometer. On postoperative day 4, the patient is not improving and is experiencing increased shortness of breath. A bronchoscopy was performed which showed mucus plugs that were removed. The patient has resolution of symptoms and his condition improves on postoperative day 6. The physician is documenting postoperative atelectasis as the diagnosis. In ICD-10-CM, this would code: Atelectasis > other/unspecified. The code would be J98.11 (atelectasis). There is documentation and clinical evidence in the medical record to support a query to the provider asking if the postoperative atelectasis is a complication from the surgery or an expected outcome of the procedure. Should the physician concur that it was a complication, this would code: Atelectasis > postoperative complication. The ICD-10-CM codes would be J95.89 (other post procedural complication and disorders of the respiratory system, not elsewhere classified) and J98.11 (atelectasis). The additional code is based on the instructional note to use additional code to further specify the disorder.

Postoperative Shock

Per coding guidelines, shock is classified as a complication when it occurs in the postoperative period. ****** In this case, the physician would not have to specify a link between the shock and the procedure. In ICD-10-CM it would code: Shock > Spell other (post procedural) > unspecified > encounter (initial). The ICD-10-CM code would be T81.10XA (post procedural shock unspecified, initial encounter). This condition is a “Complication/Comorbidity (CC)”. 

When the diagnosis of post-operative shock is present, the CDI specialist should be on the lookout for a more definitive diagnosis; what type of post-operative shock does the patient have? Let’s say this patient is post-operative CABG/AVR. The patient develops hypotension with poor tissue profusion, exhibited by altered mental status and cyanotic, cool extremities. Pulses are rapid and weak, and there is decreased urine output. Echocardiogram and chest X-ray confirm heart failure. A Swan-Ganz catheter in inserted. Patient is treated with a Dobutamine drip and fluid resuscitation. There is supporting documentation and clinical evidence to initiate a query to the physician for the specificity of the shock. In ICD-10-CM, post-operative cardiogenic shock would code: Shock > Spell other (post procedural) > cardiogenic > initial encounter for code T81.11XA (post-procedural cardiogenic shock, initial encounter. Post-operative hypovolemic shock would code: Shock > Spell other (post procedural) > hypovolemic > initial encounter for code T81.19XA (other post-procedural shock, initial encounter. Not only do these diagnoses specify the type of post-operative shock, they are also major complications/comorbidities (MCCs). 

Key Notes to Consider When Coding Post-Operative Complications 

Coding guidelines are clear about coding complications of care. It is based on the physician’s documentation linking the condition to the medical care provided. Other important guidelines to remember: 

  • Not all conditions that occur in the post-operative phase are complications; look for a cause-and-effect relationship and clinical evidence of a complication. There must be a cause-and-effect relationship between the care provided and the condition, and an indication that it is a complication.
  • When in doubt, or if the documentation is not clear, query the physician for clarification.
  • There is no time limit for the development of a complication of care. It can occur during the hospital stay, shortly after discharge, or in some cases, years later, which is often seen with implants such as orthopedic devices, mesh implants, and joint replacements.
  • Post-operative complications or complications of care are defined as unexpected or unusual outcomes that occur following the care provided.
  • Specific documentation of the word “iatrogenic” literally means that the condition was caused by the physician or the medical care, for example iatrogenic pneumothorax.
  • Look for documentation such as “due to,” “resulted from,” or “the result of” to identify a complication of care.
  • If there is a causal relationship that is documented and is implicit of the condition, it is not necessary for the physician to provide further documentation for the link, for example surgical wound infection or wound dehiscence.
  • Official Coding Guidelines always take precedence over any other coding advice, including Coding Clinic. 

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