22 Apr How to Perform Medical Coding for Complications
Complications are an outcome for many patients who receive medical care, services, treatment, and medications. Coding for complications is often difficult for medical billing professionals. Because complications arise, you need a billing company who knows exactly how to code these issues.
Code assignment is driven by the provider’s documentation. For surgical procedures, you must have a relationship between the procedure and the diagnosis. Coding guidelines specify that not all conditions which arise following medical or surgical care are complications. In order to code for a complication, there must be a cause-and-effect relationship between the care given and the condition. Incomplete and/or unclear documentation requires a query to the provider for updated documentation and clarification of the situation.
Excludes and Includes Notes
There is no time limit regarding complication development. Patients may experience complications a long time after a procedure or hospitalization. Therefore, it is necessary to assign a complication code when these incidents occur. If something unusual or unexpected occurs, during or after the treatment or care, the billing professional must assign an appropriate complication code.
When assigning complications of care codes, the coder must utilize all references and resources. This includes any electronic coding software, code books, and coding reference materials. With ICD-10, the biller must use guidance offered which involves “excludes” and “includes” notes.
The ICD-10 system offers an expanded selection of complication codes. For each body system, you will have postprocedure and intraoperative complication codes. Also, the system has complication codes related to transplanted tissues and organs. Two codes are required to describe the complications of transplant. Furthermore, complication codes are used regarding injections, infusion, and transfusion, as well as implants, grafts, and prosthetic devices. The coder also must consider wound dehiscence, infection, and postoperative shock codes.
Key Elements of Coding Complications
When considering coding for complications, certain key elements exist. These include:
- Clinical indicators
- Physical examination
- Positive findings
- Treatment provided
- An assessment of the documentation
- Frequency and acuity
- Specific devices
Examples of Coding for Complications
Some examples of complication codes include:
- 84XA – Pain due to internal prosthetic devices. This code is used when the patient has pain related to a prosthetic device or implant. Additional codes are required to specify the type of pain and if or not it is related to a medical condition.
- Postoperative fever – If the physician specifies that the fever occurred after surgery, then it must be coded with a complication code. A query is necessary regarding whether the fever was a complication of the surgery. Secondary diagnoses codes must be used to show the severity of the condition and to support additional resources required in the treatment and care of the patient.
- Blood loss – Many orthopedic procedures result in blood loss, as there is cutting of bone, tissues, muscles, and other body structures. Vessels may be injured during the surgery. When a patient requires a blood transfusion, Acute blood loss anemia (D62) should be added as a secondary diagnosis.
Operative reports and physician documentation may mention lacerations. When there is little to no documentation specifying the laceration as a real complication, the billing professional should inquire and ask for information. S82.251D is a code used for displaced comminuted fracture of the right tibia shaft, which is a subsequent code used along with the external cause of injury. When a condition is caused by a physician, it is considered an iatrogenic code. This is different from a complication code.
With code T80.29XA, the infection obtained was a complication of a previous injection procedure. This is something that can occur during an arthrocentesis. For instance, the external cause code Y64.1 details the circumstances, as the substance injected was contaminated. The PCS code 0R9J3ZX is for the removal of synovial fluid from the joint. The biller will also code for chronic underlying conditions, such as adhesive capsulitis and osteoarthritis.