Tip: Watch for postop or post-traumatic infections with OR procedures

April 15, 2010

CDI specialists would do well to keep an eye on documentation leading to three MS-DRGs that multiple RACs have listed on their approved audit issues:

856 (postop or post-traumatic infection with operating room [OR] procedure with MCC)
857 (postop or post-traumatic infection with OR procedure with CC)
858 (postop or post-traumatic infection with OR procedure without CC or MCC)

If your coders and CDI team members understand which conditions drive the MS-DRGs they’ll be better prepared to submit valid queries to the physician. The following conditions will yield MS-DRG 856, 857, or 858 when paired with an OR procedure:

958.3 (post-traumatic wound infection, not elsewhere classified)
998.51 (infection postop seroma)
998.59 (other postop infection)
999.39 (complications of medical care not elsewhere classified, infection following other infusion, injection, transfusion, or vaccination)

Before reporting one of the listed conditions, ensure documentation supports that a patient truly has a postoperative infection, says Donna D. Wilson, RHIA, CCS, senior director at Compliance Concepts, Inc., in Wexford, PA.

For example, documentation may indicate that a patient has a postop fever, but this doesn’t necessarily mean coders should report 998.59. If the fever isn’t associated with a known infection, report 780.62 (post-procedural fever), which became effective October 1, 2008.

Similarly, don’t confuse seroma (i.e., a collection of clear fluid) with hematoma (i.e., a collection of blood), says Wilson. Reporting 998.51 could yield one of the previously listed MS-DRGs whereas reporting 998.12 (hematoma complicating a procedure) would not.

Editor’s note: For additional tips, see the April issue of Briefings on Coding Compliance Strategies.

Found in Categories:

Quality & Regulatory