How to Code a Postoperative Complication

Postoperative complications are issues a patient is experiencing due to a prior surgery. These types of conditions or symptoms should be coded as the reason or diagnosis for the patient's encounter with the physician. These complications should be coded in addition to an encounter code for the patient's visit. This visit will typically be a follow-up visit with the physician after surgery to evaluate the patient's healing progress and assess any other patient concerns. There is no time limitations on coding postoperative conditions.

Things You'll Need

• Medical record
• History of preoperative condition
• ICD-9 code book

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Instructions

• 1

  Gather all documentation for both the pre and postoperative conditions. Check the patient's medical history to determine the original chief complaint or reason for the surgery. Also familiarize yourself with the CPT procedure code for the patient's surgery. Make sure the patient's current condition is directly related to the surgery and that it is not typical to the specific surgery.

• 2

  Look up specific postoperative complications in the ICD-9 alphabetical section. Check the code referenced here in the tabular (numeric) section to make sure the conditions exactly match the complications the physician has reported. If no specific postoperative condition is listed, refer to the ICD-9 tabular section for postoperative complications and explanations. These codes are in the 996 to 999 range. This sections includes codes for all complications of surgical and medical care, not elsewhere classified.

• 3

  Call a representative with the patient's insurance company if you have any questions regarding the billing of the postoperative visit and complications. Each insurance company has different coding guidelines and documentation requirements. Calling a representative will ensure the claim is correct the first time it is submitted, rather than being denied for incorrect information.

• 4

  Complete and submit the claim for reimbursement to the insurance company. The postoperative conditions are listed as the diagnosis codes for the patient encounter being billed for. Claims are then submitted online. Paper claims may also be submitted by mail for smaller physician offices, at least until the government-mandated switch to electronic health records and ICD-10 in October 2013.