ICD-10-CM Coding Guidelines state:
- The code assignment is based on the provider's documentation of the relationship between the condition and the medical care or procedure
- Not all conditions that occur during or following medical care or a procedure are complication
- There must be a cause-and-effect relationship between the care that was provided and the condition that occurred during or after the complication
- The condition cannot be routinely expected after a procedure
Some conditions that can be routinely expected after a procedure and would not be coded as a complication are:
- Some level of pain is an expected condition after surgery
- Fatigue and lack of energy
- Sore throat after anesthesia
- Nausea and vomiting from general anesthesia
- Restlessness and sleeplessness
- Flatulence
When not sure, query the provider for clarification, if the complication is not clearly documented.
