Q&A: Coding postsurgical malabsorption
Q: Should malnutrition be specially linked in the physician documentation as being due to or related to the gastrointestinal (GI) surgery to use code K91.2? Is it enough that the malnutrition is diagnosed/documented and the patient had recent, previous GI surgery to code K91.2? The Alphabetic Index seems to indicate that the malnutrition does not need to be specially linked or documented as “due to or related” to the GI surgery.
A: Based on the current ICD-10-CM rules, K91.2 represents postsurgical malabsorption, which is a specific diagnosis.
On your first question, yes, the link needs to be established at the level of a diagnosis of malabsorption, not just malnutrition. In other words, to reach K91.2, the record needs provider documentation of postsurgical malabsorption, malabsorption due to prior GI surgery, or a compliant clarification that establishes that diagnosis. The Official Guidelines for Coding and Reporting state that code assignment is based on the provider’s diagnostic statement that the condition exists.
On your second question, it is not enough that malnutrition is documented and the patient recently had GI surgery. That supports malnutrition only, it does not automatically support malabsorption. Those are not interchangeable diagnoses. Tube feeding, weight loss, fat and muscle wasting, recent surgery, and pressure injuries may support malnutrition, but by themselves they do not establish postsurgical malabsorption.
The Official Guidelines guide us here as well: Documentation of complications of care code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in.
It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support the fact that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.”
For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.
Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education director at ACDIS/HCPro, answered this question. Contact info@acdis.org with any questions.