This week’s topic is Documentation of Complications of Care. A complication of care is one of the more challenging aspects of coding. The guideline is clear on this topic and when in doubt, or if the documentation is not clear, query the physician for clarification. Clinical Documentation Improvement specialists can serve an invaluable role in working with providers concurrently to determine whether a condition is truly a complication of care or an expected outcome of the procedure or disease process. The reporting of all secondary diagnosis codes, including complications of care codes, must adhere to the UHDDS criteria – found in Section III of the OGCR.
ICD-10-CM Official Guidelines for Coding and Reporting
(October 1, 2016 – September 30, 2017)
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, 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.