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ICD-10 Corner: Coding Complications of Care

By Sarah Serling, CPC, CPC-H, CPC-I, CCS-P, CCS, ICD-10-CM/PCS Trainer
August 22, 2012

Not all conditions that occur during surgery or following medical care are coded as complications. Code assignment for any complications of care is based solely on the provider’s documentation of the relationship between the condition and the care or procedure.  In addition to indicating that it is a complication, the documentation must denote a cause-and-effect relationship between the care provided and the condition. Query the provider for clarification, if the complication or causal relationship is not clearly documented. 

 

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