This patient was admitted and diagnosed with coronary artery disease and underwent a coronary artery bypass graft. Postoperatively, the patient was noted to have hyperglycemia and was followed up by the Endocrine Service. The physician lists a final diagnosis of postoperative hyperglycemia. How is postoperative hyperglycemia coded?
Assign code 790.29, Other abnormal glucose, for the postoperative hyperglycemia. Any stress hyperglycemia, such as postoperative hyperglycemia, should be assigned code 790.29. 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.