Vol. 12 •Issue 17 • Page 8
ccs prep! Postoperative Complication Coding Study Guideline Offers You Help
In this issue of CCS Prep! we will address the code assignment of postoperative complications for your studying pleasure. This tends to be a difficult area of coding for beginners and seasoned coders alike. 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. Always begin your search with the ICD-9-CM index, most likely under “complications” or the disorder you are coding. It is good practice to check both places to be sure you have the right code.
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.” This will mean that in most instances, you are going to have two codes.
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 associated signs and symptoms such as fever, and the atelectasis is treated with respiratory therapy, then the physician should be queried to document postoperative atelectasis and its impact on the patient’s stay. In this case, the postoperative codes 997.3 and 518.0 would be assigned. Refer to Coding Clinic 1990 4th Quarter, p. 25. Other conditions that may be expected and not necessarily a postoperative complication are pain, fever and some expected blood loss. Remember, look for treatment or evidence that the complication is no longer expected, but is causing problems.
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 postoperative 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, in the above situation, the physician must document “acute blood loss anemia” to assign code 285.1. The applicable postoperative diagnosis must also be documented by the physician if it applies, such as “significant intraoperative blood loss” which would code to 998.11.
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 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. 7.
8. Many times, postoperative or intraoperative 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 may only be documented on the surgeon’s operative report. Be sure to read the entire operative report and progress notes.
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.
10. The term “complication” as used in ICD-9-CM does not imply that improper or inadequate care is responsible for the problem. This is a misnomer that is sometimes believed by non-coding personnel.
11. In those instances where the physician has failed to list a postoperative complication or a significant condition following surgery, but other documentation in the medical record supports the possibility that either condition exists, the physician should be queried and appropriate documentation secured before final coding is completed.
12. Review all Coding Clinic issues pertaining to postoperative complications prior to taking the test.
13. Faye Brown’s Coding Handbook, Chapter 29 has considerable information on postoperative complications. It is a good idea to review this before taking the exams.
Now, answer the following questions without using the Coding Clinics. Research the Coding Clinics mentioned in the answer key after completing the short quiz. Due to limits on space, only the codes are presented. Please refer to you ICD-9-CM code book for descriptions.
A) A patient is diagnosed by the physician with an infected gastrostomy. What is the correct code?
B) A patient is diagnosed by the physician with a clogged gastrostomy tube. What is the correct code?
C) A patient is diagnosed by the physician with postoperative suppurative peritonitis. What is/are the correct code(s)?
2. 998.59, 567.2
D) A patient is diagnosed by the physician with significant postoperative arm pain. Pain medication is switched and increased. The stay is extended. What is the correct code(s)?
3. 998.89, 729.5
E) A patient is diagnosed by the physician with postoperative pulmonary edema. Treatment is rendered to correct the condition. What is the correct code(s)?
2. 997.3, 518.4
F) A patient is diagnosed by the physician with heart failure due to mitral valve prosthesis placed three years ago. What is the correct code(s)?
1. 429.4, 428.9
3. 996.02, 428.9
G) The patient has a displaced hip prosthesis, having been placed nine months ago and is causing pain. What is the correct code(s)?
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, education and contract coding for hospitals. The corporate office is headquartered in Pawley’s Island, SC.
Coding Clinic is published quarterly by the American Hospital Association
“CPT only© 2001 American Medical Association. All Rights Reserved.”
A) 2 — 536.41 (New code in 1998 supersedes Coding Clinic 1997 3Q p. 7)
B) 3 – V55.1 (Coding Clinic 1997 3Q, p. 7)
C) 2 – 998.59, 567.2 (Coding Clinic 1995 3Q, p.5)
D) 2 – 729.5 (Coding Clinic 1993 #5, p. 7) The ICD-9-CM index entry under Pain, postoperative says to ‘see pain by site’.
E) 3 – 518.4 (Coding Clinic 1988 3Q, pp. 3-4)
F) 1 – 429.4 (Coding Clinic 1985 N-D, p. 6) 428.9 can also be used as a secondary diagnosis to further describe the condition as heart failure.
G) 3 – 996.4 (See the includes note under 996.7X, which includes conditions due to those in 996.0-996.5. However in this case, the prosthesis is displaced, so this codes to 996.4) See Coding Clinic, Nov-Dec 1985, p. 7.