Complications of Care

Coding Complications may be complicated!

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.