Complications Diagnosis coding guidelines

Documentation and coding of complications

In the MS-DRG system, many MS-DRGs require a secondary diagnosis that is classified as a complication/comorbidity (CC) or major complication/comorbidity (MCC). The Medicare definition of complication is any condition that occurred after admission. Clinicians often view the term “complication” differently than the coding perspective.

Clinically, complication means a condition that is caused by a procedure, treatment, or illness. Providers and the quality department view the word “complication” as a poor outcome.

However, “complication” as used in ICD-10-CM does not imply improper or inadequate care by the provider. Unfortunately, providers and hospitals are profiled by “complication rates” using certain ICD-10-CM codes. Examples include:

• J98.11, atelectasis
• Iatrogenic diagnoses, such as iatrogenic pneumothorax secondary to a central line insertion (J95.811 [postprocedural pneumothorax])

Some quality agencies also use post-procedural diagnosis codes such as atelectasis (J98.11) or pneumothorax (J95.811) as complications, which can be misleading.

The external quality organizations may include the Agency for Healthcare Research and Quality (AHRQ), Healthgrades, Truven Health Analytics, Vizient, and Premier, as well as state or commercial payer quality initiatives.

Types of complications

1. Complications due to a device
   • Mechanical complications usually imply the complication is of the device itself. These complications include:
     • Breakdown
     • Displacement
     • Failure
     • Leakage
     • Malfunction
     • Obstruction
     • Perforation
     • Protrusion
2. Infectious complication due to a device (e.g., involves sepsis or other infection)
   • Catheter associated urinary tract infection also known as CAUTI
3. Complications affecting body systems 
4. Complications affecting ostomy sites
5. Pregnancy complications 
6. Complications of transplanted organs 
7. Other complications of procedures