ICD 10 codes creates a lot of confusion. The most talked codes are the sequela diagnosis codes. We have already learned about sequela ICD 10 codes in my previous post.
But, sequela can be confused with the complication codes. If you are not known about complication, checkout the below definition of it.
“A complication is defined in medicine as an unanticipated occurrence or problem that arises following a procedure, treatment, or illness. This occurrence is a result of the medical care or treatment and complicates the medical care.”
” A sequela is a residual effect of an acute phase of an illness or injury that not longer exists. Sequelae may occur anywhere from days to years after the condition causing them has resolved. ICD 10 CM does not set any particular time limit for sequela.
Coding for Sequela requires two codes, one for the residual effect and one to show that it is a sequela of the original condition. For example, if a patient has a cardiomyopathy caused by past treatment with the chemotherapy drug doxorubicin, below codes should be reported;
I42.7 Cardiomyopathy due to drug and external agent
T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs
In simple language, many problems occur during or after surgical procedures which leads to complication codes, specific to that part of the body system or the organ. In medical coding language, these are Intraoperative and Postoperative complications.
Read also: How to code signs and symptoms perfectly in ICD 10
Documentation support for Complication coding
Documentation plays a key role for coding any diagnosis. Same goes with the complications. We have to always follow the phrase in medical coding “if it is not documented then it is not done“.
Hence, their should be clean and clear documentation by the provider for coding intraoperative and postoperative complication. The provider must also clearly document that the complication is related to the care or the procedure performed.
There should be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.
Do remember that not all conditions that occur during or following medical care or surgery are classified as complications.
Finally the documentation should be very specific for coding complication ICD 10 codes. Even, the documentation for coding sequela should also be clearly mentioned by the provider.
Read also: How to Clear CPC exam in First Attempt
Examples for Coding Complications
A Patient who is recovering from a cardiac surgery gets diagnosed with hypotension. The hypotension should be clearly documented by the provider that it is related to the cardiac surgery. If the cause and effect relationship is established, then we can assign code I95.81, Postprocedural hypotension.
Do not assume a cause and effect relationship with complications.
For example, a patient has a hemodialysis chronic dialysis catheter (CDC) and get diagnosed with a sepsis. Then we cannot assume that the sepsis occurred due to the CDC. A clear documentation stating that the “sepsis due to an infected CDC” or sepsis occurred due to the infected CDC should be documented by the provider for coding complication codes.
Medical coders should see the full medical report to find any cause and effect relationship. Their are many places in the medical report such as the history and physical, progress notes, operative notes, discharge summary, and consultations. Even you can check the laboratory, pathology and radiology reports to find out the complication of care.
Read also: When to use Pregnancy Complication ICD 10 codes
How to locate Complication ICD 10 codes
To locate intraoperative or postprocedural complications, refer to the main term Complications in the alphabetic index. Search for the subterm for the type of complication, such as intraoperative, hemorrhage, and then search for the subterm for the site.
For example for coding postprocedural cardiac surgery complication, subcategory I97.1 will be used for coding all the postprocedural cardiac complication.
Subcategory I97.1, Other Postprocedural Cardiac Functional Disturbances, includes cardiac insufficiency, cardiac arrest, heart failure, and cardiac functional disturbances.
Each of these diagnoses is further differentiated by whether the surgical procedure was cardiac surgery or other surgery.
I97.11 Postprocedural cardiac insufficiency
I97.110 Postprocedural cardiac insufficiency following cardiac surgery
I97.111 Postprocedural cardiac insufficiency following other surgery