Recognize when to query for ’postoperative’ complications

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, said Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, during the July 8 HCPro, Inc., audio conference, “Documentation Improvement for Postoperative Complications: Understand Coding Guidelines and Overcome Challenges.”

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

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard said. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard said.

Instead, determine what the physician does on postoperative day one for that expected condition. Even though the condition was expected, did it extend beyond the typical time frame? Different physicians, however, may provide varied answers as to what qualifies as a normal time frame for a postoperative ileus, Howard points out.

“There is no hard and fast rule about what is the expected time frame, so you need to look at all of the indications and all of the clues that are in the record,” Howard said.

Know sequencing guidelines

When an admission is for treatment of a complication resulting from surgery or other medical care, sequence the complication code as the principal diagnosis, according to the ICD-9-CM Official Guidelines for Coding and Reporting. Also, if the complication is classified to the 996 – 999 code series and the code lacks the necessary specificity to describe the complication, assign an additional code for the specific complication.

If a patient was admitted with a postoperative infection (ICD-9-CM code 998.59), report an additional code to identify the infection (e.g., sepsis or cellulitis).

On the other hand, it is sufficient to report ICD-9-CM code 998.11 for hematuria due to a procedure. It is unnecessary to also report ICD-9-CM code 599.7 (Hematuria) as a secondary diagnosis because it does not provide any additional specificity.

Determine whether condition is linked to surgery

Sometimes it’s easy to confuse the initial diagnosis of a condition that the physician diagnosis during the postoperative period as a complication.

“It may not be related to the surgery at all,” Howard said. “It just happens to occur postoperatively, and some physicians are just indicating that time frame; [the condition] occurred after surgery.”

For those cases in which the diagnosis is completely unrelated to the surgery, simply report the regular diagnosis code as opposed to the postoperative code (e.g., atrial fibrillation instead of postoperative atrial fibrillation).

Some physicians are unaware that use of the term “postoperative” by any documenting physician may inappropriately and inadvertently link the diagnosis to the surgery as a complication from a coding standpoint, said Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information Systems in Atlanta, who also spoke during the audio conference.

“To avoid the surgery being linked with an inappropriate complication, both the surgeon and all physician consultants need to document consistently for conditions following surgery,” Manchenton said.

Some physicians simply use the term “postoperative” as a time stamp as opposed to using the term to link the condition to the surgery. “Especially if there is a consultant on the case, if I feel that they have no understanding of what happens [from a coding standpoint] when they use the word ‘postoperative,’ I show them the difference,” Manchenton said.

A patient presents to the hospital and has surgery for a fractured hip. Two days after surgery, nursing inserts a straight catheter and 300 mL of urine returns. The physician documents urinary retention.

For this scenario, it’s appropriate to clarify with the physician whether urinary retention is a complication of surgery or whether it is related to some other cause, Howard said. “It could be that the urinary retention was related to the anesthesia or to medications that were provided during the postoperative period, but this may not necessarily be a postoperative complication,” she said.

Examine atrial fibrillation during postoperative period

Atrial fibrillation during the postoperative period is another condition that presents possible confusion because it is an expected outcome after cardiac surgery, which is why providers put the majority of patients on anti-arrhythmics after their procedures, Manchenton said.

Some patients may experience a little burst of an arrhythmia if they have an electrolyte disturbance because cardiac surgery patients need higher potassium and magnesium levels than the general population, Manchenton added.

“Those might not be clinically significant, but I think that is where the clarification needs to be obtained from the physician,” she said.

Note that further clarification from the physician of the clinical significance of the atrial fibrillation may also be necessary when the condition:

  • Occurs after noncardiac surgeries
  • Is difficult to control or there are indications that the atrial fibrillation is complicating care or extending the patient’s length of stay
  • Converts to other types of rhythms (e.g., atrial flutter or ventricular tachycardia)

Review case studies illustrating when to query

Case 1: An 85-year-old female is diagnosed with a colon malignancy and undergoes a partial colectomy.

Two days after surgery, she develops atrial fibrillation with a rapid ventricular rate with heart rate of 120–150 bpm and is given digoxin IV. Cardiology is consulted and the physician documents that the patient has “postoperative atrial fibrillation.”

Is a query necessary? This patient obviously had a clinically significant arrhythmia, and there was a cardiology consult, indicating active medical treatment. Despite the term “postoperative,” however, can the coder be clinically certain that the condition is directly related to the surgery, particularly for an elderly patient?

“In this particular case, obviously we would have to code the postoperative atrial fibrillation, but I believe we need to query the physician to clearly determine whether it was related to surgery or was it an incidental event that occurred after surgery,” Manchenton said.

This isn’t a question of whether the patient has atrial fibrillation, but rather whether the physician should link this condition to the surgery, Howard added.

Case 2: A 70-year-old male presents with chest pain and is found to have a dissecting thoracic aneurysm. He undergoes thoracic aneurysm repair with graft replacement. On postoperative day one, he develops atrial fibrillation and is started on an amiodarone drip. The physician documents “postoperative atrial fibrillation.”

For this scenario, it’s fairly clear and common that the atrial fibrillation is linked to the extensive cardiac surgery. However, is it clinically significant for this patient?

“That is something I cannot make a clinical judgment on, especially on day one,” Manchenton said. It is unclear whether the atrial fibrillation will continue throughout the patient’s stay and remain a condition for which he requires treatment beyond a day or two.

“We all have to come together and work as a team,” Howard said. “We need to work with the physician [to clarify] what was really happening clinically and then based on that documentation, what can be coded retrospectively to final code for these patients. When you do see ‘postoperative atrial fib,’ it is not just slapping some codes on it and moving on.”

Editor’s note: E-mail your questions to Managing Editor Doreen V. Bentley, CPC-A, at dbentley@hcpro.com.

To learn more about documentation and coding for potential complications, including postoperative anemia and postoperative fever, purchase a copy of HCPro’s July 8 audio conference “Documentation Improvement for Postoperative Complications: Understand Coding Guidelines and Overcome Challenges.

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