Pinson&Tang Resources

Coding Complications of Care

April 21, 2022

Does recent Coding Clinic advice contradict Official Coding Guidelines for coding Complications of Care?  The short answer is No. Here’s why.

Coding Clinic 2021 Second Quarter, advised to code K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure, for the serosal injury of the small intestine that required excision, although the provider had documented the injury was “inherent” to the procedure. In addition, following a query, the surgeon stated the serosal tear was "Unavoidable during extensive lysis of adhesions, not intraoperative complication."

Coding Clinic 2022 First Quarter reaffirmed this advice to code a complication code in this situation despite the surgeon’s statement it was not a complication:

“The term ‘complication’ does not imply inappropriate/inadequate care, and/or an unplanned outcome. Some issues or conditions occurring as a result of surgery are classified by ICD-10-CM as a complication whether stated or not. Although the surgeon stated that the serosal tear was unavoidable, it does not mean that the tear is not a surgical complication. For example, a serosal tear can range from a small nick requiring no treatment at all, to a major tear requiring removal of a portion of the small intestine.”

Get our CDI Pocket Guide® to learn more about coding Complications of Care.

This may at first seem contrary to the idea that physician documentation of a “complication” governs code assignment of complications of care; however, starting with the 2017 Official Coding Guidelines, Section I.B.16 for Documentation of Complications of Care was modified to read (modification in bold):

“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 an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

This phrase “unless otherwise instructed by the classification” was added one year after ICD-10 was implemented in FY2016. This instruction was added to reflect the significant refinement and reorganization of the complication of care codes within ICD-10.

In many situations, complication of care codes are now assigned simply because they occur intraoperatively or postoperatively, and therefore do not require a cause and effect relationship or specific provider documentation that a condition is a “complication.”

In the Coding Clinic case, the serosal injury occurring during the procedure is assigned to code K91.71, which specifies “accidental puncture or laceration during a procedure.” The condition required additional treatment or monitoring, i.e., meets the definition of other diagnoses according to Official Coding Guidelines Section III Therefore, the ICD-10 Tabular entry governs code assignment.

The serosal injury was clearly documented and was clinically significant particularly since an additional surgical procedure was performed to treat the injury. A query would not be required since the documentation was clear and not conflicting or confusing – even though the surgeon documented it was unavoidable due to extensive lysis of adhesions.

Coding Clinic reinforces these instructions in other scenarios:

  • For a laceration of the right atrial appendage following cardiac pacemaker lead extraction resulting in a pericardial effusion and requiring pericardiotomy and suture, assign code I97.51, Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure. See Coding Clinic 2019 Second Quarter p. 24.
  • A durotomy, or dural tear, due to previous epidural injections is assigned to code G96.11, non-traumatic dural tear. Assign code G97.41, Accidental puncture or laceration of dura during a procedure, if a durotomy occurs during a current operation. See Coding Clinic 2014 Fourth Quarter p. 24
  • For a traumatic ET intubation resulting in soft palate injury, assign code K91.72, Accidental puncture and laceration of a digestive system organ or structure during other procedure. Even if this is documented as “traumatic,” traumatic injury codes are not assigned for injuries that occur during or as a result of a medical intervention. See Coding Clinic 2019 Second Quarter p. 23.
  • For a patient who is status post colectomy presents with chills, abdominal pain, and fever, and diagnosed with anastomotic dehiscence of the small bowel to the transverse colon. Assign codes K91.89, Other postprocedural complications and disorders of digestive system, and T81.32XA, Disruption of internal operation (surgical) wound. See Coding Clinic 2020 Second Quarter 2020 p. 22.

Keep in mind that although conditions classified as complications of care are typically unexpected or unusual outcomes by the care rendered, the term “complication” as used in ICD-10 does not necessarily imply that improper or inadequate care was provided or it was a “surgical misadventure.” And many times it isn’t. Particularly with surgeries, there is always a risk of complications which do occur.

What’s important is these conditions are tracked so we have good data to improve the quality and outcomes for our patients. If we’re not coding these conditions when they occur, how can we improve the care we’re providing—and “clinical documentation integrity”?

In summary, the ICD-10-CM codes for complications of care, the 2017 Official Coding Guidelines change, and Coding Clinic instruct us to code accidental punctures and lacerations and other clinically significant conditions that occur during or as a result of medical interventions. It is not necessary to query providers for a cause-and-effect relationship or whether it complicated the procedure. When the ICD-10 Tabular entry instructs us to assign a specific code, it should be assigned unless the documentation is unclear or the condition does not meet the definition of an additional diagnosis.

(c) 2022 Pinson & Tang

See our original CDI Pocket Guide for more information on this topic.

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