As we move clinical documentation forward into the world of ICD-10 and value-based purchasing, the accurate coding and reporting of complications of care likely will become even more of an area of focus for healthcare facilities.

This increased scrutiny only will underscore the ongoing struggle to balance the accurate reporting of conditions occurring in the postoperative period with recognizing “true” postoperative complications and/or expected occurrences during or after surgery (or those that a physician may deem clinically insignificant).

Nothing in the coding guidelines has changed related to the documentation of complications of care, as evidenced by the following instruction in both the 2012 fiscal year’s ICD-9-CM and ICD-10-CM 2013 Official Guidelines for Coding and Reporting:

“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in,” the guidelines read. “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.”

However, the organization of the complication-of-care codes has changed significantly under ICD-10-CM. As opposed to ICD-9-CM, which includes the majority of complication codes in one section (titled Complications of Surgical and Medical Care, NEC, 996-999), the postoperative complication codes in ICD-10-CM are listed in diagnosis-specific body system chapters. There is no ICD-10-CM differentiation between intraoperative and post-procedural complications of care. The specific type of surgery or procedure being performed can delineate further both the intraoperative and post-procedural complication codes.

Because the organization of codes has changed so dramatically, again, the number of ICD-10-CM code options available to report complications of care has increased significantly. For example, ICD-9-CM code 998.12, Hematoma complicating a procedure, maps to 58 different ICD-10-CM codes. An example of the enhanced specificity for this code can be found in the ICD-10-CM Diseases of the Digestive System chapter:

K91.61, Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure;

K91.62, Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure;

K91.840, Post-procedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure; and

K91.841, Post-procedural hemorrhage and hematoma of a digestive system organ or structure following other procedure.

Interestingly, there are ICD-10-CM categories that combine complications and disorders in the description. For example, Category E89 (Post-procedural endocrine and metabolic complications and disorders, not elsewhere classified) includes the following two valid codes:

E89.0, Postprocedural hypothyroidism; and E89.1, Postprocedural hypoinsulinemia.

Potentially classifying these types of conditions as complications of care adds another dimension to the struggle of identifying complications related to the quality of care versus conditions that occur postoperatively and are expected procedure outcomes (i.e. postsurgical hypothyroidism). Ultimately, there needs to be collaboration with profiling organizations so members of such organizations recognize this difference when determining ICD-10 code inclusions in their rating methodologies for negative implications related to complications of care.

In summary, there is obviously more granularity in the available ICD-10-CM complication-of-care codes; however, the true representation of the quality of care provided for a patient, along with acuity of that patient and outcome data, still rests on the quality of the clinical documentation and coding. In the world of ICD-10 and value-based purchasing, the responsibility of recording accurate clinical documentation has to be a collaborative effort between all entities within a healthcare organization.

About the Author

Lisa Roat, RHIT, CCS, CCDS, is the manager of HIM product development and compliance for J.A. Thomas & Associates. In this capacity, Lisa serves as the ICD-10 technical product specialist expert and is responsible for the development of ICD-10 product and service lines for J.A. Thomas & Associates. She is an AHIMA-approved ICD-10 CM/PCS Trainer.

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