April 2009

1. April 2009 Coding of Complications Policy Paul Evans, RHIA, CCS, CCS-P, CCDS

2. To provide guidelines for the selection and coding of complications. To ensure minimal variation in coding practices and to achieve a high level of coding accuracy, integrity, and quality. Also to provide communication to our physicians as to how coding translates their medical documentation into complication codes. Purpose:

3. Proper capture and reporting of complications is imperative to accurately report the severity of illness and risk of mortality for our facility. The coding of complications is one of the more difficult coding challenges. A coder must perform a through analysis of physician documentation to determine: if a condition is reportable if that condition should be considered as a complication if there is sufficient documentation to support the code and if there is a need to query the physician regarding the potential existence of the complication. Background:

4. Additional challenge is that these codes are used as part of systems analysis to generate profiles for both physicians and facilities yet codes alone do not make any determination as to the outcome of care rendered nor do the codes reflect severity or grading. Provider documentation that a condition resulted from a treatment / procedure can be challenging due to the negative connotation that the term implies. While ICD-9 does not suggest that use of the term indicates inadequate care, many providers are reluctant to document some conditions due to third- party analysis of coded data for quality initiatives. This policy is intended to provide direction for the correct identification of complications for both our coders and physicians. Background (continued):

5. Definitions: Complication: • “a condition arising during the hospitalization that modifies the course of the patient’s illness or the medical care required” (Huffman, HIM Management.) • “A morbid process or event occurring during a disease that is not an essential part of the disease, although it may result from it or from independent causes (Stedman’s) • “Complications as any deviation from the normal postoperative course, such as arrhythmia and atelectasis. “ (Annals Surgery)

6. Definitions (continued): Complications are coded as additional diagnoses: • UHDDS: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode and have no bearing on the current hospital stay are to be excluded. • Coding Clinic: Additional conditions that affect patient care in terms of requiring: • Clinical evaluation; or • Therapeutic treatment; or • Diagnostic procedures; or • Extended length of hospital stay; or • Increased nursing care and/or monitoring

7. Coding Instructions: General Instructions: • Portions of the record that contain acceptable physician documentation to support code assignment include the diagnosis record, discharge summary, history and physical, emergency room record, physician progress notes, physician orders, physician consultations, anesthesiologist notes, and operative report/notes. Codes for diagnoses and procedures must be documented in the body of the medical record by a physician directly participating in the care of the patient. This documentation must be clear and consistent.

8. Coding Instructions (continued): General Instructions: • CPMC coders will query the attending physician for clarification if required. • Query the physician if there is a discrepancy in the record regarding diagnoses or procedures to be coded. • Also, query the physician when abnormal findings, diagnoses or procedures are documented in other areas of the medical record, such as nursing notes, respiratory therapy notes, radiology reports, pathology and laboratory reports, EKG, nutritional evaluation, medication administration, graphic record, and other ancillary reports. • Any suspected conditions must be documented by the attending physician.

9. Coding Instructions (continued): General Instructions: • To consider a diagnosis a complication: • the condition is more than a routinely expected condition or occurrence • there must be a cause and effect relationship between care provided and the condition and • must be documented • For instance, the terms documented as ‘postoperative ileus or ‘postoperative atelectasis” are coded as complications. However, the same terms listed only as ‘atelectasis’ or ‘ileus’ are NOT listed in the coding classification system as complications.

10. Coding Instructions (continued): General Instructions: • Care must be exercised to ‘err on the side of caution’- if it is not clear the condition being considered is a complication, then do not code it as a complication. • Do not assume an event, such as postoperative atrial fibrillation, should be coded as a complication. Review the medical record carefully for all preexisting conditions and be aware patient’s may experience an acute exacerbation of a pre-existing condition or previously undisclosed or unknown medical condition for a variety of reasons that may or may not be directly related to medical/surgical care. This logic will be applied to a multitude of other conditions, such as a myocardial infarction, sepsis, acute renal failure, stroke, etc. These are only coded as complications when the documentation clearly states the condition is a complication.

11. Coding Instructions (continued): General Instructions: • For ambulatory surgery patients who are subsequently admitted to inpatient status because of a complication, the principal diagnosis is the complication (reason for admission) and the secondary diagnosis is the reason for the surgery.

12. Coding Instructions (continued): Specific Instructions: Incidental Serosal Tear • CPMC will not code as this as a complication unless the record explicitly states the tear is a complication. In this, this is coded as 998.2, Accidental Tear or Puncture. • Physician Perspective: Laceration of small or large intestine during takedown of adhesions in patient who has had multiple previous surgeries or abdominal irradiation or inflammatory disease when entering the belly for intestinal obstruction due to those adhesions or for any other operative procedure, such as cholecystectomy or colon resection, etc, may be only incidental to the procedure, and should not be coded as a complication. (AHA Coding Clinic for ICD-9-CM, 3Q 1990, Volume 7, Number 3, Page 18)

13. Coding Instructions (continued): Incidental Serosal Tear (continued) Question: • Should a tear during surgery be coded to 998.2? Operative report states small tear of liver during retraction, controlled with hemopad. • When there are multiple adhesions present in the abdomen and they are lysed with a statement of duodenal serosal tears postlysis, would code 998.2 be assigned? Answer:When a tear is documented in the operative report, such as a small tear of liver during retraction, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure. Assign 998.2, Accidental puncture or laceration during a procedure. • Coder’s Perspective: Coding Clinic states “Any event that results in need to repair or reoperate because of unplanned entry into intestine, other organ or major blood vessel is a “complication”.

14. Coding Instructions (continued): Specific Instructions: Dural Tear • Tears of the Dura are always coded, but if the record does not state the dural tear is a complication, the tear is coded as incidental – 349.31. A dural tear documented as a complication is coded as 998.2, Intraoperative Tear/Laceration. (AHA Coding Clinic for ICD-9-CM, 4Q 2008, Volume 25, Number 4, Pages 109-110) • Effective October 1, 2008, new codes have been created for intraoperative incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in order to distinguish dural tears from other types of accidental surgical lacerations. The dura mater covers the spinal cord and the spinal nerves. A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intra-operatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery can result in leakage of cerebrospinal fluid (CSF), leading to CSF headache, caudal displacement of the brain, subdural hematoma, spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula. • As stated in Coding Clinic First Quarter 2006, page 15, “Dural tears are coded, because a dural tear is always clinically significant due to the potential for cerebrospinal fluid leakage.”

15. Coding Instructions (continued): Specific Instructions: Ileus • CPMC will only code this as a complication if the term ‘postoperative’ is used to describe the condition, or if the record otherwise states the ileus is a complication. A short term ileus is expected in the postoperative period for many patients. CPMC will not assume an ileus stated as ‘following GI surgery’ is a complication. • Ileus can have different relationships to the procedure and may not be related to any procedure whatsoever: • Exist before a procedure and unrelated • Exist before a procedure and due to the disease • Start after the procedure due to the disease • Start after the procedure due to a complication that occurred during the operation

16. Coding Instructions (continued): Ileus (continued) • An Ileus can be mechanical, as obstruction of the bowel, or it can be reflexic due to inflammation or as response to handling, or it may be due a current diseases, such as a neurologic or muscular dysfunction that (diabetes, Ogilvie’s syndrome, etc.) • Documentation of postoperative ileus requires the assignment of a complication code. • Example: Acute ruptured appendicitis with “postoperative ileus” = 540.0 appendicitis), and postoperative ileus (997.4 – GI Complication) and 560.1 (Ileus)

17. Coding Instructions (continued): The term Ileus is indexed as follows: • Ileus (adynamic) (bowel) (colon) (inhibitory)(intestine) (neurogenic) (paralytic) 560.1 • arteriomesenteric duodenal 537.2 • due to gallstone (in intestine) 560.31 • duodenal, chronic 537.2 • following gastrointestinal surgery 997.4 • gallstone 560.31 • mechanical (see also obstruction, intestine) 560.9 • meconium 777.1 • due to cystic fibrosis 277.01 • myxedema 564.69 • postoperative 997.4 • transitory, newborn 777.4

18. Coding Instructions (continued): Specific Instructions: Atelectasis • This condition is often only incidental, and should not always be coded. However, if it satisfies the UHDDS Definition of a Reportable Condition, it should be coded. • However, it is coded as a complication only if the record states the atelectasis is a complication or describes this as ‘postoperative atelectasis”. (AHA Coding Clinic for ICD-9-CM, 4Q 1990, Volume 7, Number 4, Page 25) Question: Is atelectasis following surgery always considered a postoperative complication? Answer: Postoperative atelectasis is often an incidental radiographic or physical finding that is frequently a self-limiting condition, in which case it would not be coded or reported. If, however, it is associated with significant findings, such as fever, or requires further diagnostic or therapeutic work up, such as chest x-ray or respiratory therapy, or is linked to an extended hospital stay, then it should be reported as 997.3, Postoperative respiratory complication.

19. Policy: SCOPE: This policy applies to Hospital Coding including Inpatient acute, Psychiatry, SNF, Acute Physical Rehab, Emergency Department, and Ambulatory Surgery. VII. OVERSIGHT: The Coding Manager will oversee the appropriate reporting and collection of hospital discharge data. VIII. EDUCATION AND TRAINING: Upon employment, each coder will be provided with a copy of this policy. Training on Policy & Procedure (P&P) for this data element provided by the supervisor.

20. Policy (continued): VIIII. AUDITING AND MONITORING: Adherence to this policy will be reviewed with each coder as part of his/her annual evaluation. Coding Manager will evaluate and monitor compliance with this policy as part of regular, ongoing quality of coding review. X. PROBLEM IDENTIFICATION: Coding Manager will review findings on assessment of each coder’s accuracy on reporting data. Coder’s should be advised of problems identified with follow-up training provided. Manager will report findings on data errors to the coder’s at the completion of data corrections. If any error trends are identified, supervisor will develop and distribute additional education and or training to coders. XI. ENFORCEMENT: Coder who is non-compliant is subject to employee corrective disciplinary action.

21. Policy (continued): XII. RESOURCES: American Hospital Association -Coding Clinic Uniform Hospital Discharge Data Set Definitions ICD-9 Official Guidelines for Coding and Reporting American Health Information Guidelines on Determining Surgical Complications California Health Information Article – Postoperative Complications by Paul Evans, RHIA, CCS, CCS-P, CCDS

22. Next Steps Thank you! • Next steps: • Recommended documentation hints for MD’s- cards, newsletter, flyers • Other ideas???