Q&A: Resolving coding postoperative ileus worries with documentation

Q: A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?

A: ICD-9-CM  Official Guidelines for Coding and Reporting state we do not report an additional diagnosis unless it’s been clinically evaluated, diagnostically tested, therapeutically treated, reduces or increases length of stay or nursing monitoring, says James S. Kennedy, MD, CCS, managing director of FTI Healthcare in Atlanta. It also states that signs and symptoms integral to disease are not reported unless otherwise required.   Given that there is no evidence that the expected postoperative ileus met the definition of an additional diagnosis, I would not add this unless directed to do so by the provider.  Additionally, it should not be coded as a complication unless the physician agrees that this was his or her intention or unless forced to by the ICD-9-CM Index to Diseases.

To better understand the situation we need to understand the definition of surgical complication. Coding Clinic, 3rd Quarter 2009, p. 5, Kennedy points out, “is probably the latest and greatest advice as to when conditions should be complications or not complications.” These three essentials are:

• First, the circumstance must be more than a routine condition or occurrence. Ileus occurs commonly after gastrointestinal surgery. In this circumstance, the physician stated at the time of discharge that the postoperative ileus is expected with this procedure.
• Second, the complication needs to be related to the procedure. “Even though an ileus is expected with most bowel surgery, and just because I have an ileus after surgery doesn’t necessarily mean it’s due to the procedure,” Kennedy says. “It could be due to a medication such as morphine. It could be due to an autonomic neuropathy.”
• Finally, if it is the physician’s intention for the circumstance to be a complication, it must be documented as such.

Essentially, the section explains that the coder cannot make a determination as to whether a condition was a complication or not—only the physician can diagnosis a condition. If the condition (in this case possible surgical complication) is not clear, that should be discussed with the physician, he says.

What makes this dicey is that the Index to Diseases classifies “postoperative ileus” or “ileus following gastrointestinal surgery” as 997.4 – Digestive system complications. If a coder went solely by the Index to Diseases, 997.4 would be coded.  Given that the physician documented “expected” postoperative ileus, wisdom dictates that the coder must be certain that the postoperative ileus met the definition of an additional diagnosis and that the surgeon truly intended for it to be a surgical complication.

“This is a sensitive subject when it comes to queries for the physicians because you need to use the word ‘complications,’” says Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, independent consultant, Orlando, FL. “Physicians typically become nervous around this word for a number of reasons. They do not want anything negative to show up on their quality report cards and, of course, they always worry about potential malpractice liabilities,” she says.

One element to communicate to physicians would be to underline how important specific documentation is to capture the difference between when a condition is an expected complication and when it is truly a complication of the surgery that was not expected, Kennedy says.

“I’ve actually seen more and more of the term ‘expected ileus’ used in the physician documentation,” says Brown. “I think it definitely does help the coders if that term is in there. If we don’t have to do a query and it is right there in the documentation, then that’s a good thing.”

Editor’s Note: This Q&A was adapted from the 2010 audio conference Top Five Coding and Documentation Challenges.