Guidelines clarify complications of care
December 3, 2012
CDI Blog - Volume 5, Issue 46
Most coders know that reporting a complication of care requires that the medical record include explicit documentation of the relationship between the condition and the procedure. Previous versions of the ICD-9-CM guidelines include this requirement in Chapter 17 (Injury and Poisoning), suggesting that it applies only to codes within the 996-999 code range. This has confused coders with respect to whether the requirement also applies to codes outside this range.
"There have been many questions posed to AHA's Coding Clinic over the years on this topic," says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. Acute hemorrhagic blood loss anemia (ICD-9-CM code 285.1), a non-Chapter 17 code, has been the focus of many of these questions.
"Even though this code is not in the complication series of ICD-9-CM codes, it is still seen at times as a complication regardless of whether it is expected," she says.
To eliminate confusion, the FY 2012 ICD-9-CM Official Guidelines for Coding and Reporting include the requirement for provider documentation under Section 1 (conventions, general coding guidelines, and chapter-specific guidelines) which state:
“The guideline extends to any complications of care, regardless of the chapter the code is located in. 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.”
This change confirms that the guideline requiring the presence of a cause-and-effect relationship applies to all complication codes regardless of the chapter in which they appear, says McCall.
"This means the provider should clearly identify and document that the condition is directly related to the procedure performed and not merely a condition that arose during a postoperative period or during an admission/encounter," she says. Terms such as "due to," "associated with," or "secondary to" help clarify this relationship.
Physicians, medical directors, or physician advisors can, and should, explain to CDI specialists and coding staff what are typically considered expected outcomes for certain procedures and what might constitute a complication.
Some ICD-10-CM combination codes denote the complication and body system affected and indicates whether the complication is postoperative, says McCall. For example, ICD-10-CM code I97.110 denotes post-procedural cardiac arrest following cardiac surgery.
Reviewing instructional notes is always important because some ICD-10-CM codes require an additional code to denote the specific condition (e.g, post-procedural heart failure requires an additional code to identify the specific type of heart failure). However, coders using ICD-9-CM always report a complication code (e.g., 997.1 for cardiac complications) and a code from the specific chapter to identify the actual complication (e.g., 427.5 for cardiac arrest).
Editor’s Note: This article first published in Briefings on Coding Compliance Strategies. For information on the ICD-10 Basics Boot Camp, visit www.hcprobootcamp.com.