We are concerned about the inconsistency in hospital coding of postoperative hemorrhage and postoperative hematoma because the coding of these conditions affect data quality. For example, when a surgical wound is slightly oozing blood and is treated with pressure, it is being coded as a postoperative hemorrhage. By the same token, if a small hematoma is noted after surgery, but not treated, it is still being coded as postoperative hematoma. Could you provide us with guidance so that we can consistently code these conditions?
The Official Coding Guidelines state in relation to complications of care: "As with all procedural or postprocedural complications, code assignment is based on the provider's documentation of the relationship between the condition and the procedure" (Section I.C.17.f.1.a). In addition, the Guidelines specify that "for reporting purposes, the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures; or increased nursing care and/or monitoring."
It is important to note that not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. Only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication. If it is not clearly documented, the coder should query the physician for clarification.