tci Outpatient Facility Coding Alert - 2018 Issue 5

CPT® Coding: Discern Between Complications and Known Surgical Risks

Know when to use the ICD-10-CM index as a reference. When it comes to coding surgical procedures and operations, coders have to know exactly how to handle complications from the procedure if and when they arise. However, how is a coder to know what categorizes as a surgical complication, as opposed to a known or expected "risk?" It seems that, depending on the operation, there are certain gray areas that exist when making the determination between what constitutes a complication versus a common result of the surgery. While some coders may not necessarily think it matters in most...

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