The term “postoperative” can be interpreted differently by clinicians and coders.
- Clinically the provider is referring to a timeframe that follows surgery without necessarily implying there is a relationship between the surgery and a particular condition.
- Coding conventions and other coding guidance may interpret “postoperative” as a complication of surgery.
- Documentation of postoperative respiratory failure will result in the assignment of a complication code.
- Updated coding guidelines for complications state, “it is not necessary for the provider to explicitly document the term ‘complication.’”
- Some conditions that occur anytime following surgery during the same admission may be classified as a complication of care.
- Patients who have elective surgery and later develop sepsis (POA=N) could be included in the population for PSI 13: Postoperative sepsis.
Providers should avoid using the term “postoperative” when describing a diagnosis unless the intent is to link the condition and the preceding procedure/surgery.
Download the complete tip, Postoperative Conditions.