It’s Complicated: Post-Operative Complications

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


By Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA

 

Coding post-operative complications has been a hot topic of late. Because of the negative impact that complications could have on quality scores, locating documentation of these events is often challenging. To receive accurate reimbursement to offset the increased use of resources, however, detailed documentation for accurate code assignment is needed. While ICD-10-CM has made it “easier” to code complications by eliminating the need for a separate complication code, the challenge for clinical documentation improvement specialists is in determining if the condition is an expected outcome of the procedure or patient’s disease process, or if it is an actual post-operative complication.

A post-operative condition must include all the following:

  • It must be more than a normal expected outcome of the procedure.
  • It must be evaluated, monitored, and treated by the provider.
  • A cause-and-effect relationship between the care provided and condition must exist.
  • The provider must clearly document that it is a complication.

There are several complications that occur post-operatively, including the following three conditions discussed in this post.

Atelectasis

Generally, atelectasis occurs in some degree for many patients undergoing an upper abdominal or thoracic surgery. It is an incomplete expansion of the lung segments and typically occurs within the first 48 hours following general anesthesia. It can be noted on a chest x-ray and normally resolves spontaneously. It can occur in a patient who is ambulatory, using routine post-operative incentive spirometry with no clinical symptoms.

Example of complication:

On post-operative day three the provider notes course lung sounds, a heart rate of 100, and WBCs of 12.2; and the patient complains of chest pain and shortness of breath. Provider orders albuterol nebulizer treatments and repeat chest x-ray which indicates no resolution of the atelectasis. If the physician documentation indicates “post-operative atelectasis,” then a query as to whether the condition is a post-operative complication may be needed.

Atrial Fibrillation

Generally, if a patient has a history of atrial fibrillation that is currently treated with medication then it would not be considered a complication. If the patient develops post-operative atrial fibrillation noted on cardiac monitoring that resolved on its own without treatment then it would not be a complication.

Example of complication:

Post-operative atrial fibrillation, even for a cardiac procedure, must be clearly documented by the physician and treated with medications or defibrillation. For example, provider documentation that “following surgery the patient’s post-operative course was complicated by paroxysmal atrial fibrillation required an amiodarone drip” would clearly indicate an atrial fibrillation complication even if the patient’s procedure was a cardiac catheterization.

Paralytic Ileus

Generally, an expected outcome of an abdominal procedure. It can be present for up to three-days post-procedure.

Example of complication:

If the patient is not experiencing normal bowel function after three days and the physician is treating the patient with a nasogastric tube, rectal tube, NPO status, a reduction in pain medication, etc. and no physician documentation is present for a possible complication, then a query may be needed.

Things to Keep in Mind

Important rules to follow when it comes to post-operative complications:

  • Not all post-operative conditions are complications.
  • There is no time limit for the development of a complication.
  • Post-operative complications are defined as unexpected or unusual outcomes that occur following care.
  • Look for provider documentation such as “due to,” “resulted from,” or “the result of.”
  • Conditions such as surgical wound infections or wound dehiscence are considered implicit of the condition and it is not necessary for the physician to further clarify the event as a complication.
  • When in doubt, query the provider.

 

Lou Ann Wiedemann has been a health information management professional for 25+ years.

Submit a Comment

Your email address will not be published. Required fields are marked *

Share This

Share This

Share this post with your friends!