Complications of care aren’t as problematic to code as they sound, but the definition is essential for you to get right. A condition is only considered a complication when the physician documents that the condition is a complication based on a cause-and-effect relationship between the care given and the condition, and the result is more than an expected outcome.
Complication of Care Documentation
According to Official Guidelines for Coding & Reporting FY2020 Section 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 where the code is located.
NOTE: Not all conditions that occur during or following medical care or surgery are classified as complications. You must have 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.
Surgical & Medical Complications
In Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88), you will find complication codes under category T80-T88 Complications of surgical & medical care, not elsewhere classified.
NOTE: Make sure you go to the beginning of this category to read notes applicable to this entire code block. This note references two conventions: “use additional code” and “excludes 2.”
The “use additional code” note reminds you to consider other supporting codes to identify adverse effects of drugs, medicaments, and biological substances, as well as a resultant condition.
These can be:
- Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
- Use additional code(s) to identify the specified condition resulting from the complication
- Use additional code to identify devices involved and details of circumstances (Y62-Y82)
Y62-Y82 includes complications of medical devices as the cause of abnormal reaction of the patient or identifies a later complication that was not mentioned at the time of the procedure.
An example of this is Y79.1 (Therapeutic (non-surgical) and rehabilitative orthopedic devices associated with adverse incidents) such as the cause of a pressure ulcer from a prosthetic limb.
Include Excludes 2 Notes
An “excludes 2” note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. Remember when an “excludes 2” note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. In this case, for example, there is an excludes 2 for artificial opening status (Z93.-) and colostomy malfunction (K94.0-)
Reminder: the “excludes 2” represents “not included here.”
NOTE: To look up a complication in the alphabetic index for surgical wound complications, search under the type of complication (e.g. Disruption; Infection, post-operative).
Surgical Wound Complications
Complications of surgical wounds includes T81.3- (wound dehiscence) T81.4- (postoperative wound infections), and T81.89- (non-healing surgical wounds).
You will find wound dehiscence in the alphabetic index under disruption (of), closure of, by site. T81.31- includes closure of skin, subcutaneous tissue, full thickness skin, superficial disruption of operative wound while T81.32- includes: fascia, muscle flap, tendon, deep disruption of dehiscence of operation wound NOS. Dehiscence of obstetric incisions, dehiscence of amputation site incisions, and suture complications are excluded (excludes 1) from T81.31- and require assignment of more specific codes.
You must review the documentation for the type of disruption to provide the level of specificity. T81.4- identifies if an infection develops post-operatively and has a use additional code note to identify infection and a use additional code note to identify severe sepsis if applicable.
The CDC provides a definition for the depth of a surgical wound infection by superficial incisional infection, deep incisional and organ and space site which is needed to properly code T81.4- Infection following a procedure. To view this definition, view this checklist PDF from the CDC: https://www.cdc.gov/nhsn/pdfs/checklists/ssi-checklist-508.pdf.
Stoma Complications
Complications of stomas are coded in the body system chapter but may still be referenced under complication in the alphabetic index. To look up a complication in the alphabetic index, search under “Complication” first then locate the correct subterm for the type of complication (e.g. Complication, colostomy) colostomy (stoma) K94.00.
If you are having difficulty finding ostomy complications, simplify your search by finding Complication, artificial, opening. For example: the index shows clearly that cecostomy, colostomy are coded to as K94- while nephrostomy, ureterostomy and urethrostomy are coded to N99.5-.
TIP: When sequencing a colostomy infection; code the colostomy complication followed by the infection.