Q&A: Unavoidable complications

Q: If a complication is clearly documented as unavoidable or due to a complex situation, should it be coded even if an intervention was done to correct it? My concern is if a complication is unavoidable and has been documented as such, is there a good enough reason to not code it, similar to how we do not code a PSI if it was an inherent part of the procedure?

For example, the provider did a removal of malfunctioning pacemaker, and inserted a new pacemaker. Ending up with pneumothorax is never inherent to this procedure. The physician, however, documents that the patient had extensive adhesions, and a complicated anatomy, due to which this unfortunate complication happened, and that it was unavoidable. Are any complications that the physician says are unavoidable to be considered inherent to procedure, and not be coded?

A: In the case you are describing, since the provider has described it as being unavoidable— meaning that the objective of the procedure could not have been completed without the complication—I would consider it inherent to the procedure and would not code it.

I would think in this situation the objective of the procedure was to remove the pacemaker. Although a pneumothorax would not be a common complication of such a procedure, the provider is describing a situation that he could not have completed the procedure without the pneumothorax, meaning the adhesions were so thick, widespread, or complicated that, to free the device, the pneumothorax occurred. In this case, I would not code this as a complication of the procedure. As you know, we cannot assign a complication code without direct documentation by the provider indicating a complication occurred.

I do suggest when such issues occur that, if you feel the provider is not being honest about the situation, perhaps they have a peer review where another surgeon reviews the case. This would not change the codes assigned as we must assign codes based on provider documentation.

However, it could allow for follow up or provider counsel if negative patterns in behavior are found to exist. Such follow up should not be performed by coding or CDI, but perhaps the quality department or risk management.

Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.