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Complication coding is a hot topic among coding, clinical, and compliance professionals. It’s considered to be one of the more challenging aspects of coding. Physicians are hesitant to document post-operative complications, as they negatively affect their quality scores on sites like Healthgrades.com. Hospitals, however, need to be compensated for the extra resources and care provided when such a condition arises. That is why clinical documentation improvement (CDI) specialists need to work with providers to determine whether a complication is truly a “post-operative complication” or an expected outcome of the procedure or disease process.


Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM Practice Excellence for AHIMA. In her role she provides professional practice expertise to AHIMA members, the media and outside organizations on coding and clinical documentation improvement (CDI) practice issues. She authors material for and supports AHIMA online ICD-10 coding education platforms. She also serves as faculty for the AHIMA ICD-10-CM/PCS Academies and CDIP Exam Preps. In addition, Ms. Endicott is a technical advisor for the Association on ICD-10-CM/PCS, ICD-9-CM, CPT coding and CDI publications.

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