Postoperative Complications: Tips for Clarifying A Diagnosis of Complications vs. Expected Outcomes

What Is a Postoperative Complication?

A postoperative complication is any condition that develops due to performance of a surgery/procedure and is undesirable or unexpected. Some examples of postoperative complications are infection, bleeding, shock, ileus, respiratory failure, etc. Sometimes it can be challenging to determine if a postoperative complication code should be reported for a condition because not all conditions that occur after a surgery/procedure are considered complications. The assignment of postoperative complication codes is based on the provider’s documentation. The provider must document the relationship of the condition to the procedure as a complication. Sometimes, if the provider doesn’t document the relationship, a query can be sent for clarification.

How Do You Determine if a Postoperative Complication Code Is Reported?

There is no time frame given for a postoperative complication to be reported. Complications can occur immediately after the procedure, or years after the procedure. Certain provider documentation implies a postoperative complication without a query needed, such as postoperative infection, postoperative hemorrhage/hematoma/seroma, and complications of internal/implanted devices (e.g., pain, mechanical issues), etc.

Examples of Provider Documentation Implying Complication:

• “Postoperative wound infection following cholecystectomy”
• “Postoperative hemorrhage following mastectomy”
• “Postoperative hematoma following thyroidectomy”
• “Displaced hardware after fracture repair”

Careful review of the documentation from the provider is necessary. The provider must clearly document that the condition is a complication of the procedure. In some cases, it must be determined whether a condition is part of the normal healing process, an expected outcome of the procedure, or in fact, a complication.

For example, postprocedural fever is reported with R50.82, which is a code from the symptom chapter and not a complication code. This simply means that the patient developed a fever after the procedure, but it is not considered a complication of the procedure.

Another example is postoperative anemia. This is a common condition that occurs after surgery but is usually not a complication. The provider may document “postoperative anemia due to acute blood loss”. This is reported with D62, Acute posthemorrhagic anemia, rather than a complication code unless it is documented as “anemia complicating the procedure,” or with other similar statements establishing a complication.

A postoperative ileus is a common condition that develops after gastrointestinal surgery and involves disruption of normal bowel function. Symptoms of postoperative ileus include nausea, vomiting, abdominal bloating, and decreased flatus and stool output. A short duration of symptoms after surgery are expected, but when the ileus is severe or prolonged, IV fluids, or nasogastric tube decompression may be necessary. In these cases, sending a query to the provider may be needed to clarify if the ileus is a postoperative complication. If postoperative ileus is not a complication, it is reported with K56.7-Ileus, unspecified. If the ileus is a complication, two codes are needed to describe the complication, K91.89, Other postprocedural complications and disorders of digestive system, and K56.7, Ileus unspecified.

How Do You Clarify if a Postoperative Issue Is a Complication or Expected Outcome?

Determining when a postoperative condition is an actual complication of a procedure is important because complications can negatively affect the facility financially, operationally, and through quality scores regarding Patient Safety Indicators (PSI). Also keep in mind that when considering reporting of a postoperative complication, the condition must meet the requirements for reporting additional diagnoses, meaning it was clinically significant and required clinical evaluation, treatment, monitoring/increased care, and/or extended length of stay (ICD-10-CM Official Guidelines for Coding and Reporting, Section III. Reporting Additional Diagnoses). If the condition does not meet requirements for reporting as a secondary diagnosis, a query clarifying whether the condition is a complication is not necessary because the condition is not reportable.

References

• CDI Pocket Guide by Pinson&Tang
• ICD-10-CM Official Guidelines FOR Coding and Reporting 2025
• AHA Coding Handbook

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.