We Query to clarify if it is an actual complication or is "Post-Op" the "timeframe", as in after operation but not a complication.
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
Linnette Wert RHIT, CCS
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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.
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.
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
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.
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.
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.
unwanted sequel leads to an increased risk of thromboembolism and necessitates further often costly health care.
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.