Transcript Coding of Complication Policy

Coding of Complications Policy
Paul Evans, RHIA, CCS, CCS-P,
CCDS
April 2009
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Purpose:
To provide guidelines for the selection and coding of
complications.
To ensure minimal variation in coding practices and
to achieve a high level of coding accuracy, integrity,
and quality.
Also to provide communication to our physicians as
to how coding translates their medical documentation
into complication codes.
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Background:
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Proper capture and reporting of complications is
imperative to accurately report the severity of illness
and risk of mortality for our facility.
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The coding of complications is one of the more difficult
coding challenges. A coder must perform a through
analysis of physician documentation to determine:
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if a condition is reportable
if that condition should be considered as a
complication
if there is sufficient documentation to support the
code and
if there is a need to query the physician regarding
the potential existence of the complication.
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Background (continued):
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Additional challenge is that these codes are used as part of
systems analysis to generate profiles for both physicians and
facilities yet codes alone do not make any determination as to
the outcome of care rendered nor do the codes reflect severity
or grading.
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Provider documentation that a condition resulted from a
treatment / procedure can be challenging due to the negative
connotation that the term implies. While ICD-9 does not
suggest that use of the term indicates inadequate care, many
providers are reluctant to document some conditions due to
third- party analysis of coded data for quality initiatives.
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This policy is intended to provide direction for the correct
identification of complications for both our coders and
physicians.
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Definitions:
Complication:
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“a condition arising during the hospitalization that
modifies the course of the patient’s illness or the
medical care required” (Huffman, HIM Management.)
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“A morbid process or event occurring during a disease
that is not an essential part of the disease, although it
may result from it or from independent causes
(Stedman’s)
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“Complications as any deviation from the normal
postoperative course, such as arrhythmia and
atelectasis. “ (Annals Surgery)
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Definitions (continued):
Complications are coded as additional diagnoses:
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UHDDS: All conditions that coexist at the time of
admission, that develop subsequently, or that affect the
treatment received and/or the length of stay. Diagnoses
that relate to an earlier episode and have no bearing on
the current hospital stay are to be excluded.
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Coding Clinic: Additional conditions that affect patient
care in terms of requiring:
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Clinical evaluation; or
Therapeutic treatment; or
Diagnostic procedures; or
Extended length of hospital stay; or
Increased nursing care and/or monitoring
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Coding Instructions:
General Instructions:
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Portions of the record that contain acceptable physician
documentation to support code assignment include the
diagnosis record, discharge summary, history and
physical, emergency room record, physician progress
notes, physician orders, physician consultations,
anesthesiologist notes, and operative report/notes.
Codes for diagnoses and procedures must be
documented in the body of the medical record by a
physician directly participating in the care of the
patient. This documentation must be clear and
consistent.
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Coding Instructions (continued):
General Instructions:
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CPMC coders will query the attending physician for
clarification if required.
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Query the physician if there is a discrepancy in the
record regarding diagnoses or procedures to be coded.
Also, query the physician when abnormal findings,
diagnoses or procedures are documented in other areas
of the medical record, such as nursing notes, respiratory
therapy notes, radiology reports, pathology and
laboratory reports, EKG, nutritional evaluation,
medication administration, graphic record, and other
ancillary reports.
Any suspected conditions must be documented by the
attending physician.
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Coding Instructions (continued):
General Instructions:
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To consider a diagnosis a complication:
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the condition is more than a routinely expected
condition or occurrence
– there must be a cause and effect relationship between
care provided and the condition and
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must be documented
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For instance, the terms documented as ‘postoperative
ileus or ‘postoperative atelectasis” are coded as
complications. However, the same terms listed only
as ‘atelectasis’ or ‘ileus’ are NOT listed in the coding
classification system as complications.
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Coding Instructions (continued):
General Instructions:
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Care must be exercised to ‘err on the side of caution’- if it is
not clear the condition being considered is a complication,
then do not code it as a complication.
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Do not assume an event, such as postoperative atrial
fibrillation, should be coded as a complication. Review the
medical record carefully for all preexisting conditions and
be aware patient’s may experience an acute exacerbation of
a pre-existing condition or previously undisclosed or
unknown medical condition for a variety of reasons that
may or may not be directly related to medical/surgical care.
This logic will be applied to a multitude of other
conditions, such as a myocardial infarction, sepsis, acute
renal failure, stroke, etc. These are only coded as
complications when the documentation clearly states the
condition is a complication.
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Coding Instructions (continued):
General Instructions:
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For ambulatory surgery patients who are
subsequently admitted to inpatient status because of
a complication, the principal diagnosis is the
complication (reason for admission) and the
secondary diagnosis is the reason for the surgery.
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Coding Instructions (continued):
Specific Instructions:
Incidental Serosal Tear
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CPMC will not code as this as a complication unless the
record explicitly states the tear is a complication. In this,
this is coded as 998.2, Accidental Tear or Puncture.
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Physician Perspective: Laceration of small or large
intestine during takedown of adhesions in patient who
has had multiple previous surgeries or abdominal
irradiation or inflammatory disease when entering the
belly for intestinal obstruction due to those adhesions or
for any other operative procedure, such as
cholecystectomy or colon resection, etc, may be only
incidental to the procedure, and should not be coded as
a complication. (AHA Coding Clinic for ICD-9-CM,
3Q 1990, Volume 7, Number 3, Page 18)
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Coding Instructions (continued):
Incidental Serosal Tear (continued)
Question:
– Should a tear during surgery be coded to 998.2? Operative report
states small tear of liver during retraction, controlled with hemopad.
– When there are multiple adhesions present in the abdomen and they
are lysed with a statement of duodenal serosal tears postlysis, would
code 998.2 be assigned?
Answer: When a tear is documented in the operative report, such as a small
tear of liver during retraction, the surgeon should be queried as to
whether the small tear was an incidental occurrence inherent in the
surgical procedure or whether the tear should be considered by the
physician to be a complication of the procedure. Assign 998.2, Accidental
puncture or laceration during a procedure.
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Coder’s Perspective: Coding Clinic states “Any event that results in need
to repair or reoperate because of unplanned entry into intestine, other
organ or major blood vessel is a “complication”.
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Coding Instructions (continued):
Specific Instructions:
Dural Tear
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Tears of the Dura are always coded, but if the record does not state the
dural tear is a complication, the tear is coded as incidental – 349.31. A
dural tear documented as a complication is coded as 998.2, Intraoperative
Tear/Laceration. (AHA Coding Clinic for ICD-9-CM, 4Q 2008, Volume 25,
Number 4, Pages 109-110)
Effective October 1, 2008, new codes have been created for intraoperative
incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in
order to distinguish dural tears from other types of accidental surgical
lacerations. The dura mater covers the spinal cord and the spinal nerves. A
tear in the dura that occurs during spinal surgery is not unusual and is
typically repaired intra-operatively when identified. Primary closure of the
dural tear is usually accomplished. Dural tears that are not discovered
during surgery can result in leakage of cerebrospinal fluid (CSF), leading to
CSF headache, caudal displacement of the brain, subdural hematoma,
spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula.
As stated in Coding Clinic First Quarter 2006, page 15, “Dural tears are
coded, because a dural tear is always clinically significant due to the
potential for cerebrospinal fluid leakage.”
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Coding Instructions (continued):
Specific Instructions:
Ileus
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CPMC will only code this as a complication if the term
‘postoperative’ is used to describe the condition, or if
the record otherwise states the ileus is a complication.
A short term ileus is expected in the postoperative
period for many patients. CPMC will not assume an
ileus stated as ‘following GI surgery’ is a complication.
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Ileus can have different relationships to the procedure
and may not be related to any procedure whatsoever:
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Exist before a procedure and unrelated
Exist before a procedure and due to the disease
Start after the procedure due to the disease
Start after the procedure due to a complication that occurred
during the operation
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Coding Instructions (continued):
Ileus (continued)
 An Ileus can be mechanical, as obstruction of the bowel, or
it can be reflexic due to inflammation or as response to
handling, or it may be due a current diseases, such as a
neurologic or muscular dysfunction that (diabetes,
Ogilvie’s syndrome, etc.)
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Documentation of postoperative ileus requires the
assignment of a complication code.
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Example: Acute ruptured appendicitis with “postoperative
ileus” = 540.0 appendicitis), and postoperative ileus (997.4
– GI Complication) and 560.1 (Ileus)
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Coding Instructions (continued):
The term Ileus is indexed as follows:
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Ileus (adynamic) (bowel) (colon) (inhibitory)(intestine) (neurogenic)
(paralytic) 560.1
arteriomesenteric duodenal 537.2
due to gallstone (in intestine) 560.31
duodenal, chronic 537.2
following gastrointestinal surgery 997.4
gallstone 560.31
mechanical (see also obstruction, intestine) 560.9
meconium 777.1
due to cystic fibrosis 277.01
myxedema 564.69
postoperative 997.4
transitory, newborn 777.4
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Coding Instructions (continued):
Specific Instructions:
Atelectasis
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This condition is often only incidental, and should not always be coded.
However, if it satisfies the UHDDS Definition of a Reportable Condition,
it should be coded.
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However, it is coded as a complication only if the record states the
atelectasis is a complication or describes this as ‘postoperative
atelectasis”. (AHA Coding Clinic for ICD-9-CM, 4Q 1990, Volume 7,
Number 4, Page 25)
Question: Is atelectasis following surgery always considered a postoperative
complication?
Answer: Postoperative atelectasis is often an incidental radiographic or
physical finding that is frequently a self-limiting condition, in which case
it would not be coded or reported. If, however, it is associated with
significant findings, such as fever, or requires further diagnostic or
therapeutic work up, such as chest x-ray or respiratory therapy, or is
linked to an extended hospital stay, then it should be reported as 997.3,
Postoperative respiratory complication.
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Policy:
SCOPE: This policy applies to Hospital Coding including
Inpatient acute, Psychiatry, SNF, Acute Physical
Rehab, Emergency Department, and Ambulatory
Surgery.
VII. OVERSIGHT: The Coding Manager will oversee the
appropriate reporting and collection of hospital discharge
data.
VIII. EDUCATION AND TRAINING: Upon employment, each
coder will be provided with a copy of this policy. Training on
Policy & Procedure (P&P) for this data element provided by
the supervisor.
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Policy (continued):
VIIII. AUDITING AND MONITORING: Adherence to this policy
will be reviewed with each coder as part of his/her annual
evaluation. Coding Manager will evaluate and monitor
compliance with this policy as part of regular, ongoing quality of
coding review.
X. PROBLEM IDENTIFICATION: Coding Manager will review
findings on assessment of each coder’s accuracy on reporting
data. Coder’s should be advised of problems identified with
follow-up training provided. Manager will report findings on
data errors to the coder’s at the completion of data corrections. If
any error trends are identified, supervisor will develop and
distribute additional education and or training to coders.
XI. ENFORCEMENT: Coder who is non-compliant is subject to
employee corrective disciplinary action.
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Policy (continued):
XII. RESOURCES:
American Hospital Association -Coding Clinic
Uniform Hospital Discharge Data Set Definitions
ICD-9 Official Guidelines for Coding and Reporting
American Health Information Guidelines on Determining Surgical
Complications
California Health Information Article – Postoperative Complications
by Paul Evans, RHIA, CCS, CCS-P, CCDS
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Next Steps
Thank you!
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Next steps:
– Recommended documentation hints for
MD’s- cards, newsletter, flyers
– Other ideas???
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