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Tip of the Week: Coding Complications of Care

By Connie L. Zeller, CPC
September 26, 2012

Coding complications of medical care or treatment is entirely dependent on the physician’s documentation of the relationship between the condition and the medical care or procedure. However, it is important for coders to know that conditions may occur during or following medical care that are not automatically classified as complications. The provider must indicate that the condition is a complication and clearly document a cause-and-effect relationship. If the complication is not clearly documented, the provider should be queried for clarification.

 

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