Conquering documentation of complications in ICD-10-CM

March 15, 2024

When a patient is admitted for treatment of complication resulting from medical or surgical care, the principal diagnosis should be the complication. An ICD-10-CM code for the specific complication may be assigned as a secondary diagnosis if it provides greater specificity about the nature of the condition.

Coders should not assign an additional code when the complication code itself completely describes the condition. Traumatic injury codes should not be assigned for injuries occurring during or as a result of medical intervention.

Code assignment is based on the provider’s documentation of the relationship between the condition and the procedure, unless otherwise directed by the ICD-10-CM classification. Not all conditions occurring during or following medical care or surgery are considered a complication. The provider must document both the cause and-effect relationship and an indication that the condition is a complication.

Coders should query the provider for clarification if the documentation is not clear if the condition is a complication.

A code is not typically assigned for an expected condition following surgery when:

• The condition did not persist beyond the expected timeframe
• There was no treatment directed toward the condition
• It did not extend the patient’s length of stay

For more on documentation and coding of complications, read the full article in JustCoding.

Amanda Vincent, MBA, CCS, CPC, CCDS, CRC, is a clinical developmental analyst at 3M Health Information Systems.