Recognize when to query for ’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, said Audrey G.
Howard, RHIA, senior consultant for 3M Health Information
Systems in Atlanta, during the July 8 HCPro, Inc., audio
conference, “Documentation Improvement for Postoperative
Complications: Understand Coding Guidelines and Overcome
Challenges.”  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 oc