Coding, Classification & Reimbursement

Subject: ICD-10-CM Postoperative Atrial Fibrillation

1.  ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-14-2017 15:21
How are you coding postoperative atrial fibrillation?  In ICD-9 it was indexed under atrial fibrillation, postoperative, and it coded to  997.1, cardiac complications.  In ICD-10, postoperative is not indexed under Afib.  I've still been following the coding clinic advice to assign a cardiac complication code for postoperative atrial fibrillation."  But, I'm getting push back.  The discharge summary reads, "patient had postoperative  paroxysmal atrial fibrillation, managed by Dr. x."  I coded the the complication code, and the afib code, both with POA of "N"   Not coding the afib, or just coding the afib without the complication description, doesn't seem to capture the accurate picture of the patient encounter.   Thoughts?

Thank you .

Christine 


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Christine Dundas
Medical Coding Program Coordinator
Miami Dade College
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2.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-15-2017 06:01
Hello!

I think you are assigning the correct codes.  That is how I code postoperative atrial fib.  However, a certain Encoder assigns different complication codes depending on how what pathway you use to arrive at your codes.  I cannot be more specific right now.  Just be sure the complication code is the correct one.

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Lawrence Barr
President
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3.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-15-2017 09:41

We Query to clarify if it is an actual complication or is "Post-Op" the "timeframe", as in after operation but not a complication.

 

Example Query:

Post Operative Ileus documented as treated with NG. Please clarify if this a post operative complication or  "post operative" is the timeframe that the ileus occurred

1) post operative complication

2) post operative wording is the timeframe the ileus occurred

 

 

Thank You,

Linnette Wert RHIT, CCS

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4.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-15-2017 10:35

Per the index, if you look up postoperative you will see an entry for postoperative(postprocedural), it directs you to see complication, postoperative. At that point, you are directed to see complications, postprocedural. At that point there is a direction to see also complications, surgical procedure. Under complications, postprocedural, there are many complications, including hematoma, hemorrhage, seroma, plus entries for every other organ system. Listed immediately below the complications, postoperative entry are a few entries that direct you to see complications of circulatory, ear, endocrine, eye, nervous, and respiratory system, and CSF leak following LP. So,based on the classification, we would automatically assign a complication code for anything that is diagnosed as postoperative/postprocedural.

In the Conventions Section I. 16 documentation of complications of care, it states Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The bolded portion was new to this year's classification.

Is the provider simply documenting a time frame, and it is not necessarily a complication? That's the way it used to be and we would query. Or is postoperative enough to make the link? It seems to me the classification is telling us to automatically link it.




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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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5.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-16-2017 05:13

99% of the time the MD reply is "Timeframe". We found it is better to Query an eliminate an audit denial and then the need to adjust payment.

 

Thank You,

Linnette Wert RHIT, CCS

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6.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-16-2017 08:47

​Reporting complications has significant implications for facility quality metrics and Value Based purchasing, and should be reported with great care.

Be cautious that it should not be assumed that a condition that occurs in the post operative period, should automatically be coded as a post operative complication; even if the indexing for "postoperative" takes you there.

Our organization reached out to the AHA regarding the reporting post operative respiratory failure because the indexing for Failure, respiratory, postprocedural, acute or acute on chronic map to ICD-10-CM diagnosis codes J95.821 and J95.822 respectively.

The AHA's response to us supported that just because a condition occurs in the post-operative period, does not support that the condition was due to the surgery, and that the "postprocedural" and "postoperative complication" codes do indicate that the condition was due to the surgery.

One case scenario:  a patient with severe copd has surgery and postprocdurally the patient has a copd exacerbation with acute hypoxic respiratory failure.

In this instance, the appropriate reporting of the claim would be the AECOPD and acute respiratory failure with J96.01 (N), and not J95.821 because the acute respiratory failure was not due to the surgery.

There are many scenarios that conditions occur in the post operative period, but not due to the surgery These should not be reported as procedural complications.

I encourage each of you to reach out to the AHA with  scenarios to continue to validate and report complications correctly,

There is also a great resource on the AHRQ website that discusses coding considerations when reporting complications - Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research & Quality

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Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research & Quality
The Toolkit for Using the AHRQ Quality Indicators (QI Toolkit) is a free and easy-to-use resource for hospitals planning to use the AHRQ Quality Indicators (QIs), including the Patient Safety Indicators (PSIs), to track and improve inpatient quality and patient safety. The QI Toolkit also may serve as a general guide to applying improvement methods in a hospital setting.
View this on Ahrq >






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Suzanne Drake
Coding Quality and RAC Coordinator
Bon Secours Richmond Health System
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7.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-17-2017 22:54
​Coding Clinic 4Q 2013 pg 98-99 specifically states in the answer to "code 997.1, Cardiac complications for postoperative atrial fibrillation. This code assignment is specifically indexed under "fibrillation" "postoperative" and  code 427.31, atrial fibrillation should be reported as an additional diagnosis code to specify the complication".  It is my interpretation that if you go to the specific condition (not just looking up Postoperative -see complication, postoperative) and there was a "postoperative" option then it can be assigned without a query.  An exception to this being Infarction, cerebral, postprocedural because there is Specific Guideline I.C.9.c. relating to Intraoperative and Postprocedural cerebrovascular accident which states documentation must clearly specify the cause and effect relationship between the medical intervention and the CVA in order to assign a code. I think this is what is meant by Guideline I.B.16 Documentation of Complication of Care- Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complication of care.  The Classification assumes the link between the postoperative option under specific conditions.  If this is not the case, then Coding Clinic needs to print a clarification.

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Karen Neal
Coding Quality Auditor
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8.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-18-2017 07:30

Karen,

Then following that coding clinic you sited we would not code it to post-op Afib since in I-10 there is no complication directive under Fibrillation, Atrial and a Query would be needed.

 

Thank You,

Linnette Wert RHIT, CCS

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9.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-20-2017 22:53
​Yes, I agree queries would be needed in ICD10 for both postop afib and postop ileus as the Index has removed the "postoperative" option in ICD10.  However, a diagnosis of postoperative hypotension would be assigned I95.81, or a diagnosis of postoperative hypertension would be assigned I97.3, and postoperative fever  would be assigned R50.82. The Classification makes the linkage between these conditions. An exception to this would be postoperative cerebral infarction because the Guidelines have a specific guideline(I.C.9.c) that requires the physician to make the link. In ICD9, there use to be a "postoperative" option for postoperative confusion which indexed to 293.9 which was a CC.  In ICD10 there is not an option for postoperative confusion, so the physician would need to be queried.  Also the physician's documentation would have to state "postoperative", it would not apply to documentation of hypotension, or fever occurring in the postoperative time frame unless the physician was queried.

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Karen Neal
Coding Quality Auditor
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10.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-19-2017 09:06
Hi Karen:

I agree that you should always first check under the specified condition to see if that is specifically indexed. Another example of this would be postoperative fever- R 50.82. I like what you have to say regarding not to assume the postprocedural and code from that, however, I don't see how this holds up. Why then, didn't they index it as postoperative complication- see complications postoperative? That to me would mean further query may be necessary.

If you look under diabetes-with- they do have items such as neurologic complications, opthalamic complications, other complications, etc. In these cases, we would need the MD to clearly state the connection- for example, diabetes complicated by glaucoma. I would think they would follow the same logic in this case if that was their intent. It appears to me that they are indicating that postoperative, when part of the diagnostic statement, is making the link between the procedure and the condition. If a condition occurs after the surgery but is not specified as postoperative, then I would not code it as a complication or look under postoperative in the index, unless specifically documented as a complication of the procedure.

I do think that more should be done to highlight this significant change.

Here is a short YouTube clip describing this from Barry Libman of Libman Education:

ICD-10 Coding Clinic Update: ICD-10-CM Index Post-op Complication

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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11.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-18-2017 10:29
Suzanne:

Was the diagnosis written as "postoperative respiratory failure?" If not, how was it worded?

Thanks,
Jodi

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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12.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-19-2017 10:55
​HI Jodi,

Below is the question that was submitted to the AHA for respiratory failure.

I do disagree that documentation of "postoperative" in the record should be reported as a complication without query if the index takes you there, if there is other clinical information in the record that suggests the condition is due to something else, other than the surgery.

AHIMA and query practices have long supported that any time a physician uses terminology, and there is a question of his/her intent when using that terminology, that a query is appropriate.

In the case of documentation of postoperative respiratory failure, if there is clinical support/documentation such as "postoperative respiratory failure due to copd" or "postoperative respiratory failure due to chf"; we do generate a query asking the physician to clarify if the physician is inferring that the condition is due to the surgery, or occurring in the post operative period and due to the other documented acute condition.


Suzanne





Q: The ICD-10-CM index for Failure, respiratory, post procedural maps to J95.821 for acute postprocedural respiratory failure or J95.822 for acute on chronic postprocedural respiratory failure

 

When is it appropriate to report post-procedural respiratory failure? Is it appropriate to report any time that respiratory failure occurs after surgery?  Or is post procedural respiratory failure reported any time that acute or acute on chronic respiratory failure occurs after a surgical procedure has been performed?

 

Example: A 87 year old patient with a known history of COPD presents to the ER after a ground level fall.  An intertrochanteric fracture is found on xray.  The patient is admitted and a THR is performed.  After surgery, the patient has an acute exacerbation of her copd which develops to acute hypoxic respiratory failure.

 

What is the correct reporting of the acute hypoxic respiratory failure?

 

Is it reported with J96.01 for acute hypoxic respiratory failure because it was due to the copd and not due to the surgery; or is it reported with J95.821 for acute postprocedureal respiratory failure?

 

Another example might be a patient who aspirates after surgery, develops aspiration pneumonia and acute hypoxic respiratory failure.

 

Is the acute hypoxic respiratory failure reported with J96.01 because the acute hypoxic respiratory failure was due to aspiration pneumonia? Or is it correct to report it to postprocedural acute respiratory failure because the episode of respiratory failure occurred after the surgical procedure?

 

This distinction has significant impact on Quality metrics, so is critical to understand correct reporting.



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Suzanne Drake
Coding Quality and RAC Coordinator
Bon Secours Richmond Health System
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13.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-19-2017 11:18
Thanks Suzanne:

I do agree with you that if the record is indicating the issue is due to another condition, then you should not code it as a complication, or query as you stated. I had this discussion with someone else and pointed out this very issue. So, if the condition was found to be a chronic issue that just happened to be noticed after surgery, it would not be a complication. But if the diagnosis for example states "postoperative atrial fibrillation", and there is no documentation to state that this is due to another unrelated condition, then it would be a complication, based on the index and guidelines.

I do understand, based on your wording of the questions to Coding Clinic that these would not be complications, because you did not state the diagnosis as postoperative respiratory failure. So, the answer Coding Clinic gave you makes perfect sense. I've had cases that stated acute respiratory failure without further qualification, that did occur after surgery. In this case, I would only assign the acute respiratory failure diagnosis. If it is specifically stated as postoperative respiratory failure, then I'd use the J95.821 code. This is because postprocedural is an essential modifier. So we can't assign post-procedural "x" (x meaning any diagnosis) unless the MD specifically includes that in the diagnostic statement.

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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14.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-15-2017 10:47
Dear Christine,

Since you have the actual ICD-9 code I would go on GEM and see what the code corresponds to in ICD-10. Just make sure that the ICD-10 codes which are provided are supported by the documentation and the guidelines.

Jodi Miller, RHIT, CCS

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Jodi Miller, RHIT, CCS
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15.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-17-2017 07:44
​Hello!

So if a patient is diagnosed with a postoperative wound infection do you query the physician and if the response is "timeframe", not assign a "complication" code?  The term complication does not necessarily mean something was done wrong.

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Lawrence Barr
President
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16.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-18-2017 07:26

Hello,

No, post op wound infection is coded to post op wound infection without query.  Infection is a "complication" of the operative wound where as AFib or Ileus as examples could just be an expected occurrence after an operation.

HcPRO did a nice article in 2012 regarding post operative complication coding.

http://www.hcpro.com/HIM-281812-5707/Tip-Coding-for-inpatient-postoperative-complications-requires-explicit-documentation.html

 

Thank You,

Linnette Wert RHIT, CCS

The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer

 






17.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-19-2017 05:41
​Hello!

Per, http://www.sid.ir/en/VEWSSID/J_pdf/86820031-413.pdf.  "Atrial fibrillation (AF) is a common complication of heart surgery. This

unwanted sequel leads to an increased risk of thromboembolism and necessitates further often costly health care. 



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Lawrence Barr
President
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18.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-20-2017 06:19

Hello,

Great article on Afib post surgery. Using your article as an example, In the codebook, Afib does not have a complication or post-op directive, but thromboembolism does have a postoperative directive and would direct you to code it as complication. In the  I-9 codebook there was a AFIb post-op directive, I-10 doesn't have that directive.

It would REALLY be nice if the Coding Clinic would be clearer and consistent with guidelines. Case in point, post op ileus this article http://www.practicalgastro.com/pdf/December02/BehmArticle.pdf mentions significant morality, as in the Afib article, but coding clinic directs the coder to clarify.

The facility I am contracted to work has decided through query to have the physician make the decision as to complication or timeframe.

 

Thank You,

Linnette Wert RHIT, CCS

The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer

 






19.  RE: ICD-10-CM Postoperative Atrial Fibrillation

Posted 06-21-2017 06:37
Edited by Lawrence Barr 06-21-2017 08:42
Hello!

Now I am looking at this from the "query" standpoint.  Articles I have read regarding query for postop complications are for the most part, if not all, consistent with those presented in this article:  Q&A: Use yes/no queries to resolve surgical complication questions | ACDIS Blog
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Q&A: Use yes/no queries to resolve surgical complication questions | ACDIS Blog
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication.
View this on Hcpro >
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Is including the option "Timeframe" leading?  One could argue that all "postoperative" conditions are an issue of "Timeframe".
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