Guest Post: Postoperative complication coding and value-based purchasing

by Ghazal Irfan, RHIA

Achieving compliant coding

Postoperative complication coding guidelines continue to cause difficulties for coders and CDI professionals. So, let’s analyze the steps needed to ensure complete, accurate, and compliant coding.

The first step in compliance is defining a postoperative complication. In general, a postoperative complication is an unanticipated outcome (in the form of a condition or a disease) that develops following an illness, treatment, or procedure.

For example, a 60-year-old female comes in for a herniorrhaphy (hernia repair). She has a past medical history of hypertension and morbid obesity with body mass index greater than 40. She smokes and has chronic obstructive pulmonary disease (COPD). Surgery goes well; however, post-surgery, the patient has a hard time weaning off of the ventilator and is immediately given inhaler treatments and placed on BiPAP. After a couple of incentive spirometry sessions and inhaler treatments, the patient feels better, and she is discharged home the following day.

The body of the operative report documents the patient’s inability to breathe on her own due to “acute respiratory insufficiency following extubation.” The header of the operative report, however, documents no complications. How should acute respiratory insufficiency following extubation be coded? Should it be coded as a “postoperative complication,” or as an “acute respiratory insufficiency?”

The ICD-10-CM Official Guidelines for Coding and Reporting states that “code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in.”

The Guidelines go on to explain that “it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.”

Keeping these rules in mind, a coder cannot report the diagnosis as a postoperative complication due to the legal ramifications of these codes, and due to the conflicting documentation: acute respiratory insufficiency following extubation versus no complication.

When to query

While deciding on a secondary diagnosis, coders and CDI specialists need to ask questions like:

• “Was the condition clinically evaluated, tested, and treated?”
• “Did the condition result in extended length of stay?”
• “Did the condition require increased nursing care?”

Patients who are smokers with COPD and morbid obesity have a hard time clearing their lungs of carbon dioxide and need a little help to get the gas exchange going. Since a coder/CDI specialist is not a doctor and cannot assume a cause-and-effect relationship, the coding guidelines will direct them to query the physician regarding postoperative complication.

The following query form can be used for any postoperative complication clarification and should be made part of the legal medical record.

Chances are, an inexperienced coder will look at the operative report, assign the postoperative complication code as not present on admission (POA-N), and drop the chart. Such an assignment negatively affects the facility’s quality outcomes report since postoperative complication codes with POA N are counted as the Agency for Healthcare Research and Quality’s patient safety indicators. A seasoned coder/CDI specialist, however, would submit a query and ask for clarification. Accurate, complete, and compliant coding can only be achieved when coders and CDI specialists have leadership support and physician buy-in. Coders need education on the significance of reaching out to physicians when coding postoperative complications, and when documentation is conflicting or inconsistent, even though the DRG stays the same.

Also, managers should not penalize coders for holding charts or failing to meet productivity benchmarks when pursuing a clarification. Code assignment affects reimbursement, quality outcome reporting under the VBP program, and academic research programs. Working collaboratively—coders, CDI professionals, and physicians—can assist facilities in gathering the most complete and accurate data sets, which will result in valid, ethical, and reliable quality outcomes reporting.

Editor’s note: This article originally appeared in JustCoding. Irfan is the coding compliance manager of hospital services for RevWorks AH-Corp and works with her team to ensure revenue cycle compliance. She holds a degree in health information management and is pursuing a master’s degree in biomedical informatics at Oregon Health and Science University. Opinions expressed are that of the author and do not represent HCPro or ACDIS.