ICD-10-CM Postoperative Complication Coding...Is it Confusing?

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Medical Coding Leave a Comment

ICD-10-CM Postoperative Complication Coding...Is it Confusing?

The ICD-10-CM coding of complications, specifically “postoperative respiratory failure” can result in a quality flag with PSI 11. This diagnosis can also impact the Medicare Severity Diagnosis Related Group (MS-DRG) relative weight and ultimate payment. Clinical documentation can be challenging, even confusing. Sometimes the provider is conducting ventilation management postoperatively which results in their documentation stating, “Postoperative Respiratory Failure”, but this can be a routine, expected and normal part of the immediate postoperative period. Striving for and achieving accurate documentation and coding doesn’t always come easy, so there are some considerations to take to break down the confusion.

We’ve all heard in our HIM Coding careers that the coding of complications, especially postoperative complications can be challenging and confusing. Yes, I would agree with that, but there are some solutions to help make it easier and produce accurate coding. In particular, we need to pay attention to the documentation and the coding of postoperative respiratory failure and its relationship to the Patient Safety Indicators or PSIs. Let’s also not forget that inpatient coding can result in the capturing of Major Complication and Comorbidities (MCC) and Complication/Comorbidity (CC) which impact the Medicare-Severity Diagnostic Related Group (MS-DRG). The Office of Inspector General (OIG) has released audit information regarding potential compliance overpayment concerns for MS-DRGs with a single MCC or CC.

The meaning of “Postoperative” of often thought of as 1) relating to, occurring in, or being the period following a surgical operation postoperative care. 2) having recently undergone a surgical operation. Knowing and understanding clinical aspects of the disease process is vital for Coding and Clinical Documentation Integrity (CDI) professionals. According to an article published by the National Institute of Health (NIH), Postoperative Respiratory Failure or PRF, is a frequent "postoperative pulmonary complication, it is defined by impaired blood gas exchange appearing after postoperative diagnosis associated with surgery. PRF leads to longer hospital stays and higher mortality. The time frame for recognizing when respiratory failure is related to the surgical-anesthetic insult remains imprecise, however, researchers have used different clinical events instead of blood gas measures to define the outcome." Source: February 2014 https://pubmed.ncbi.nlm.nih.gov/24240985/

In the late 1990s, facilities used to keep Coronary Artery Bypass Graft (CABG) patients on postoperative mechanical ventilation for at least 48 hours as a matter of routine surgical care (hospital course). Then, we saw “newer medicine” suggest and encourage cardiac surgeons to move their patients off the vent around or by the 24th hour in patients who were extremely healthy pre-operatively.  

In 2015 the National Institute for Health published another article that included some Centers for Medicare and Medicaid Services (CMS) inpatient hospital data indicating that the mean extubation time (that which CMS is using to calculate it's expected relative weights (RWs) and length of stays - LOS) was 10.21 hours (plus or minus 4 hours). That means that TECHNICALLY, the patient encounter would be over the Medpar data averages at 15 hours on ventilation. See Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671154/

When it comes to hospital inpatient PSIs, it is PSI 11 that focuses on postoperative respiratory failure and includes: Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases per 1,000 elective surgical discharges for patients ages 18 years and older Acute respiratory failure diagnosis codes: ICD-10-CM J95.821 Acute postprocedural respiratory failure or ICD-10-CM J95.822 Acute and chronic postprocedural respiratory failure. See Source: https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/v2020/TechSpecs/PSI_11_Postoperative_Respiratory_Failure_Rate.pdf

The first place to go for coding information, is the Official Guidelines for Coding and Reporting (OCG) and read over guideline #16 16 found in Section I of the OGC.

Documentation of Complications of Care Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.

Also, read over AHA Coding Clinic guidance, of which there are several regarding respiratory complication coding and ventilation and the expected outcome immediately after surgery. These “expected” conditions should not be coded as a postoperative complication, however, if in doubt you should query the provided.

  • See other AHA Coding Clinic advice: 2017 Q1, pages 25, 29 & 30
  • See other AHA Coding Clinic advice: 2016 Q4, page 9-10
  • See other AHA Coding Clinic advice: 2014 Q4, page 6
  • See other AHA Coding Clinic advice: 2004 Q3, page 11
  • See other AHA Coding Clinic advice: 2006 Q2, pages 8-9
  • See other AHA Coding Clinic advice: 1992 Q2, page 14

Having an appropriate query to clarify the condition of “postoperative respiratory failure” needs to be in place. Ask the question regarding the respiratory failure being integral to the surgery, especially major surgery in which the patient was vented during the surgery and continued at the end of the procedure.

With many neuro procedures, providers want to keep the patient sedated and quiet. Thus, if the patient remains on the ventilator for greater than 48 hours but that was the surgical plan, this is not postoperative respiratory failure and documentation clarification would be needed. But if the plan was immediate extubation after surgery (first postoperative day) and we are now at 24 hours or longer post-surgery and still on the vent, you need to ask the question, WHY? Is there conflicting clinical documentation regarding a postoperative condition/complication?

Some surgeons routinely document "Postoperative Respiratory failure" in the immediate postoperative period (e.g., post-CABG) to justify medical necessity for CPT codes 94002–94003 for “ventilator management”. A best practice occurring in some facilities is to work with their Medical Staff (Cardiac Surgeons, Anesthesiologist, Pulmonologist and Intensivists) and develop a clinical protocol or guideline regarding certain major surgeries in which patients are intubated and what the routine expected postoperative ventilation timeframe might be, this is something to discuss with your physician leadership and consider.

Ultimately each HIM Coding and even the CDI professional needs to ensure they are looking, reviewing and reading the FULL healthcare encounter. Utilize their knowledge coupled with the guidelines, AHA Coding Clinic to make a determination if the postoperative condition is really a complication or an immediate expected outcome of surgery. Every day we continue to strive for accuracy and truthful documentation in all patient encounters and that is what being an HIM Coding and CDI professional is about.

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