What are Comorbid and Complications in Inpatient Coding

We have learned a lot about outpatient coding, diagosis coding guidelines and CPT codes. But, today we will try to learn about inpatient coding guidelines. Here also, we have a lot of terms like POA indicators, Comorbid condition and complications which need to be learnt before coding inpatient charts. I have shared lot of information on Knee surgery, hip arthroplasty, suture removal, wound debridement, spinal epidural injection, AV fistula, angioplasty and stent placement  etc. where we are using CPT codes.

But, in inpatient coding we have different codes for all these procedures. We will learn more about it. First we will gain some knowledge about Comorbid conditions and Complications.

Comorbid Conditions

A comorbid condition is a pre-existing condition that will, because of its presence as a secondary diagnosis along with a specific principal diagnosis, cause an increase in the patient’s length of stay and additional treatment.

A comorbid condition definitely increases the reimbursement when it is present. When such a pre-existing conditions is present, it will be obvious the requirement for patient care will increase.

In Outpatient coding, we are having CPT codes for procedures but in Inpatient coding we have ICD 10 PCS codes for procedures. Along with diagnosis codes, we have to use MS-DRG codes as well.

In Inpatient Coding, when MS-DRG codes are assigned, the comorbid condition is always taken into consideration, which increase the reimbursement.

For example, a patient is admitted for treatment for pneumonia but he or she may be having CHF (Congestive heart failure) as pre-existing condition. Now, the physician has to treat CHF as well as pneumonia, hence the cost of service will increase. Hence, the reimbursement will also increase proportionally. CHF meet the definition of a secondary diagnosis.

Now, in above scenario, the MS-DRG will differ. While coding only for pneumonia, the DRG will be of less dollar value but will the entry of CHF, the DRG code will be different and will have high value than the previous one. This is the actual effect of Comorbid condition.

Hence, in Inpatient coding do not miss any Comorbid condition, because they are mainly responsible for increase the payment of services. If missed, the physician or hospitals will be paid less from the payer or insurance companies.

Read also: What are POA indicators in Inpatient Coding?

Complications

Complication is similar to comorbid condition but it occurs after the patient is admitted to the hospital. It is not a pre-existing condition like Comorbid condition.

Complication also affect the treatment received to the patient. This definitely will increase the length of stay of patient in hospital. Hence, this will obviously increase the reimbursement.

Complication also should be reported as secondary diagnosis. The only exception to this is a situation when a patient is admitted for the treatment of a complication that occurred during a previous admission. In such scenario, the complication meets the definition of a principal diagnosis.

It should be clearly documented and therapeutically treated to Justify the coding a complication. The complication must also increase the extended length of stay, increasing the patient care services.

Read also: Sample Questions and Answers for Inpatient Coders

The condition should not be a part of routine care of an expected procedure. The physician must agree and must document that the condition is a complication.

Do query the provider when the documentation is not clear for coding complication. For example, when the progress note documents the postoperative fever, we can go ahead and report it as complication. But, when the provider only documents fever during a postoperative period, we need to query the physician where it is a complication of the procedure performed.