Q&A: Unavoidable complications

Q: If a complication was unavoidable, and has been documented as such, is that good enough reason to not code it? We wouldn’t mark a code as a patient safety indicator if it was an inherent part of the procedure, so would the same hold true for unavoidable complications?

For example, the provider removed a malfunctioning pacemaker and put a new pacemaker in. The patient had a pneumothorax and the physician documented it as an unavoidable complication. As you know, ending up with pneumothorax is never inherent to this procedure but the physician also documented that the patient had extensive adhesions and a complicated anatomy, due to which this unfortunate complication happened.

I am trying to get my understanding about these concepts right. Wouldn’t this give surgeons a reason to back out of documenting complications by simply proclaiming it as unavoidable? I apologize if I sound like I am splitting hairs, but I just want to make sure we are doing the right thing, in line with the compliance and honesty of our profession.

A: 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. 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. We cannot assign a complication code without direct documentation by the provider indicating a complication occurred.

I do suggest, that perhaps when such issues occur, that if you feel the provider is not being honest about the situation, have a peer review, another surgeon, review the case. This would not change the codes assigned as we must assign codes based on provider documentation but it might allow such incidents to be followed up or provide counsel if negative patterns in behavior are found to exist. Such follow up should not be performed by coding or CDI professional but the quality department or risk management.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.