EmailACS 1904 - terms that indicate a procedural complication
Publication Date: June 2019
ICD 10 AM Edition: Tenth edition
Query Number: 3511
ACS 1904 Procedural Complications states that the terms 'secondary to' or 'due to' infer a causal relationship between a condition and a procedure in contrast to terms such as 'postop', 'following' or 'associated with'.
Can the VICC please clarify whether the term ‘complicated by’ also infers a causal relationship and how ACS 1904 should be applied in the following scenarios?
Scenario 1: Progress notes state 'femoral hernia repair complicated by ileus.'
Scenario 2: Progress notes state 'total hip replacement complicated by acute myocardial infarction on day 2 post op.'
Can the VICC please clarify whether the term ‘complicated by’ also infers a causal relationship and how ACS 1904 should be applied in the following scenarios?
Scenario 1: Progress notes state 'femoral hernia repair complicated by ileus.'
Scenario 2: Progress notes state 'total hip replacement complicated by acute myocardial infarction on day 2 post op.'
Response
VICC considers that the documentation of ‘complicated by’ in these scenarios is not clear as to whether the medical condition was a complication of the procedure (i.e. a direct causal relationship) or arose following the procedure.
Acute myocardial infarction and ileus are examples of medical conditions listed in the Intraoperative/postoperative medical conditions section of ACS 1904 Procedural complications, and may have a multifactorial cause, therefore the causal relationship must be explicitly documented (see Examples 1, 2, 4 and 5).
Therefore, VICC advises to assign I21.9 Acute myocardial infarction, unspecified and K56.7 Ileus, unspecified for these scenarios. This does not preclude generation of a query to the clinician to clarify whether the medical condition was a complication due to or secondary to the procedure.
Acute myocardial infarction and ileus are examples of medical conditions listed in the Intraoperative/postoperative medical conditions section of ACS 1904 Procedural complications, and may have a multifactorial cause, therefore the causal relationship must be explicitly documented (see Examples 1, 2, 4 and 5).
Therefore, VICC advises to assign I21.9 Acute myocardial infarction, unspecified and K56.7 Ileus, unspecified for these scenarios. This does not preclude generation of a query to the clinician to clarify whether the medical condition was a complication due to or secondary to the procedure.
