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Coding for inpatient postoperative complications requires explicit documentation

Capture appropriate documentation for coding postoperative complications.

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”

For a condition to be considered a postoperative complication all of the following must be true:

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.

Editor’s Note: This article first published on

To register for the July 12 program visit

A few post-call thoughts regarding post-operative pulmonary insufficiency and electronic queries

Quarterly Conference Calls offer members opportunties to network and share best practices..

Editor’s Note: During last Thursday’s ACDIS Membership Quarterly Conference Call the Advisory Board discussed documentation requirements for post-operative respiratory failure and post-op pulmonary insufficiency among other topics. These calls, which are free to ACDIS members, allow participants to pose a question and gain feedback and perspective from the Board and other peers. Typically, upwards of 200 people join the call.

The following post was submitted by Janie Brown, RN, CDI specialist, at The Indiana Heart Hospital in Indianapolis. Contact her at

ACDIS members can download a recording of this and all previous, archived editions of the call from the ACDIS website.

When I started the CDI program here at The Indiana Heart Hospital (TIHH) nearly two years ago, I was also looking for some direction regarding how to document and code for respiratory failure/post-operative pulmonary insufficiency. For me, the AHA’s Coding Clinic for ICD-9-CM guidelines were unclear. So, I worked with our pulmonary critical care physician, Franklin Roesner, MD, one of our cardiac surgeons  Bob Shoemaker, MD, and our Senior Medical Records Coder Debbie Dinsmore, to develop some internal guidelines for the use of the diagnosis of post-op pulmonary insufficiency.  The definition we used is “a decrease in normal pulmonary function due to trauma to the thoracic cavity and or surgical intervention.”

The guidelines we ask our physicians to consider are as follows:

  • Has pulmonary/critical care medicine been consulted?
  • Has the patient experienced increased oxygen requirements over time?
  • Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
  • Are chest x-rays being frequently monitored?
  • Are pleural effusions being monitored or treated?

I have been known to “swoop” down to the SICU when I see a nephrologists typing in “respiratory failure” on a post-op emergent cardiac surgery who remains on the vent at 0800 after returning from the operating room at 0300 to just gently say, “are you sure you want to say that?”

We are very aware of the dangers of overusing this diagnosis here at TIHH and I think the development of our own internal guidelines has greatly assisted us in staying on the straight and narrow.  We do not tend to include this diagnosis unless respiratory issues continue to greatly affect the patient’s progress on post-op day three or four.

In reference to using all electronic medical records:  TIHH is the only hospital in our network that is all electronic.  When I started here, our training consisted of learning to leave paper queries.  I had no place to leave a paper, so I was forced to talk to my physicians. That turned out to be the biggest blessing in disguise I have probably ever experienced.

In my opinion, whether you are using paper or a computer for documentation, there is absolutely no substitute for the face-to-face exchange of thoughts and information when seeking to attain accuracy and completeness in the medical record.  My advice to any CDI specialist is to get out of the office and away from the desk and talk to your physicians face-to-face.

Words to clarify by

Use these common phrases as clues for further investigation.

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

Take 10 steps to refresh your documentation review process

Ensure your CDI programs examines patient records "door-to-door."

I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.

I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.

Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?

Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?

Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.

Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.

Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.


Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.


I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

  • Physician response rates
  • Severity of illness (SOI)/risk of mortality (ROM) data
  • Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.


Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.

Cardiomyopathy: A Valentine’s Day documentation reminder

Happy Valentine's Day from ACDIS

Editor’s Note: Have a little extra thrum in your heart due to the trappings of the day? We did. So we’ve picked up this piece written by ACDIS Advisory Board members Robert S. Gold, MD, originally published in the December 2011 edition of our sister publication Briefings on Coding Compliance Strategies.

Cardiomyopathy (CMP), a disease that affects the heart muscle, is frequently misreported. When cardiologists document the term “CMP,” it usually denotes their awareness that the patient has a sick heart. They may evaluate the heart as being dilated and as having a low ejection fraction. However, they don’t always evaluate pathophysiology. Without this evaluation, documentation of CMP can be deceiving. When coders see this documentation, they report ICD-9-CM code 425.4 for the CMP even when the patient may have something else.

A quick Google search yields a variety of causes of cardiomyopathy. There are specific ICD-9-CM codes in the 425 code series for each type of cardiomyopathy. For example:

  • Codes 425.11 and 425.18 denote idiopathic hypertrophic cardiomyopathy with or without obstruction, respectively.
  • Code 425.5 denotes alcoholic cardiomyopathy.
  • Code 425.7 denotes nutritional cardiomyopathies, such as due to amyloidosis and beriberi. Some very rare cardiomyopathies are also specifically named in this section. Two examples are endocardial fibroelastosis (code 425.3) and obscure cardiomyopathy of Africa (code 425.2).
  • Code 425.8 denotes other specified cardiomyopathies in diseases classified elsewhere that can also affect the heart muscle and its function. These include Friedreich’s ataxia, progressive muscular dystrophy, sarcoidosis, and myotonia atrophica.

Other specific causes of cardiomyopathy are not included in the 425 code series.

If you look for hypertensive cardiomyopathy in the Alphabetic Index of the ICD-9-CM manual, it leads you to hypertension with cardiac involvement. This leads you to the 402–404 code series.

Hypertensive cardiomyopathy is a type of cardiomyopathy; however, it doesn’t exist in the 425 code series. Coding Clinic, Second Quarter 1993, p. 9, instructs coders to assign both the 402 (or 404) series code and code 425.8 to designate cardiomyopathy in diseases classified elsewhere.

Similarly, ischemic cardiomyopathy (code 414.8) is not listed under cardiomyopathy even though it is a cause of heart disease that can lead to dysfunction. No advice exists for the addition of code 425.8 even though it is among the most frequent causes of cardiomyopathy in the United States. This represents an error in the coding system. ICD-9-CM code 414.8 denotes ischemic heart disease just as codes 403 and 404 denote hypertensive heart disease. They each require code 425.8 to capture the complete description of the condition.

Several Coding Clinic references cite code 425.4 (other primary cardiomyopathies) for cardiomyopathy. These references state that coders should report this code for cardiomyopathy that includes such terms as “congestive,” “constrictive,” “familial,” “idiopathic,” “restrictive,” or “obstructive.” However, these references are incorrect. Code 425.4 should be used only for primary cardiomyopathies not otherwise specified or when physicians document one of the aforementioned nonessential modifiers.

When a patient has cardiomyopathy that is secondary to another condition—and the cause is unknown—coders should report code 425.9 (secondary cardiomyopathy, unspecified). When the cause is known, they should report code 425.8. These codes (i.e., 425.8 and 425.9) should be used when documentation includes any one of the nonessential modifiers listed under code 425.4 and when the cardiomyopathy is due to another condition.

The term “idiopathic” means that the physician cannot determine the cause of the cardiomyopathy despite extensive workup. If the physician can determine the cause, then by definition it’s secondary cardiomyopathy.
Ischemic heart disease is a disease classified elsewhere. Similarly, hypertension is a disease classified elsewhere. Therefore, code 425.8 should be added to 414.8 (other specified forms of chronic ischemic heart disease) for ischemic cardiomyopathy.