Coding complications can be challenging at times for coders and even clinicians. The coding of complications should be based on the documentation in the medical record, the Official Guidelines for Coding and Reporting (OGCR), or both. It is imperative that no matter the coder’s opinion on how the case should be coded, the OGCR is followed first and foremost.

When to Query?

If the documentation is unclear, then the provider should be queried for clarification.

When not to Query?

If the documentation is clear and there is official coding guidance then that should be followed, and the physician should not be queried for clarification.

According to ICD-10-CM Official Guidelines for Coding and Reporting I.B.16: 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.

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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”.

Let’s review a few AHA Coding Clinic® scenarios that provide advice on when it would be appropriate to report a complication and a query is not required.

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AHA Coding Clinic®3^rd Quarter 2019 pages 15-16: “Malposition of central venous catheter” clarifies that ICD-10-CM categorizes a device that is not positioned in the intended vessel as a complication. Regardless of the device has not caused a complication, the device is not in the correct vessel.

AHA Coding Clinic®2^nd Quarter 2019 page 7: “Acute renal failure due to dehydration” and AHA Coding Clinic^© 3rd Quarter 1998 page 6 “Kidney Transplant with renal failure” both address AKI affecting the function of a transplanted organ.

AHA Coding Clinic®2^nd Quarter 2019 pages 6 – 7: “Aspiration pneumonia and lung transplant” advised that aspiration pneumonia affects the function of a transplanted lung and would be coded as a complication.

AHA Coding Clinic®2^nd Quarter 2011 page 6: “Delayed graft function following kidney transplant” advised that a complication of transplanted organ code should be reported.

AHA Coding Clinic®1^st Quarter 2010 pages 11 -12: “Enterotomy of small intestine w/full-thickness serosal tear “advised that a complication of the procedure is appropriate to be reported for the scenario as it was more than a minor tear.  The surgeon documented that the enterotomies were clinically significant and a complication of the procedure.

AHA Coding Clinic®4^th Quarter 2008 pages 109 – 110: “Accidental dural tear” advised that reporting a dural tear as a complication is appropriate.  A dural tear is considered clinically significant because of the potential for cerebrospinal fluid leakage.

Finally, as a reminder, when deciding the appropriate code assignment based on the documentation and guidance provided, remember the coding guideline I.C.A.19 Code assignment and clinical criteria: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

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