Postoperative complications can be general or specific to the particular surgery. They are an important cause of morbidity, mortality, extended hospital stay and increased costs. Some examples of postoperative complications are wound infections, coronary artery bypass graft thrombosis, infected joint prosthesis and pulmonary emboli within one week of surgery.
Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Inaccurate coding of these complications can negatively affect profiles.
ICD-10-CM has made it easier to code complications by eliminating the separate complication (996-999) from ICD-9-CM and incorporating intra-operative and post-procedural complications into the separate body systems. For such complicated documentation, most healthcare practices now consider medical coding outsourcing.
Appropriate ICD-10 Codes for Certain Post-operative Conditions
Codes used vary depending on the fact whether the reported condition is an expected outcome of the surgery or complication.
Paralytic Ileus: Postoperative ileus is a malfunction of intestinal motility after major intra-or extra-abdominal surgery. But generally most surgeons consider the ileus which is present up to three days post-procedure as an expected outcome. In that case, the condition would be coded as “K91.3” (post-procedural intestinal obstruction). But after three days, if the patient is not experiencing a return of normal bowel function, it is likely to be a complication. In such cases, post-operative paralytic ileus can be coded as –
- K91.89 – Other post-procedural complications and disorders of the digestive system
- K56.0 – Paralytic ileus (to specify)
Atrial Fibrillation (AF): Post-operative atrial fibrillation (POAF) is a frequent complication occurring in almost half of the patients after cardiac surgery. Factors that consider AF as an expected outcome are – patient having a history of AF and the condition resolved on its own without treatment. However this is a complication, if it required treatment, either with medications or defibrillation. The physician has to specifically document that the post-operative atrial fibrillation is a complication of the procedure.
For instance, to document paroxysmal atrial fibrillation, the code to use would be “I48.0”. To document the post-operative course that is complicated by paroxysmal atrial fibrillation requiring amiodarone drip, the code would be –
- I97.89 – Other post-procedural complications and disorders of the circulatory system, not elsewhere classified
- I48.0 – Paroxysmal atrial fibrillation (to specify the disorder)
Atelectasis: It is an extremely common post-operative complication that occurs after most abdominal or trans-thoracic procedures. However, it is an expected condition that occurs within the first 48 hours postoperatively. If the condition improves in 3 to 6 days after albuterol nebulizer treatment every 4 hours and a bronchoscopy, the physician documents it as diagnosis. The code used would be “J98.11” for atelectasis. If the physician reports the disorder as a complication, then the code would be –
- J95.89 – Other post procedural complication and disorders of the respiratory system, not elsewhere classified
- J98.11 – atelectasis (to specify)
Coding experts at professional medical billing and coding companies will adhere to standard coding guidelines while documenting these complications. Certain considerations when coding include-
- Look for clinical evidence that indicates the disorder as a complication
- Clarify unclear documentation
- Remember usages such as “due to,” “resulted from,” or “the result of” indicates complication of care