What is the primary factor for assigning codes related to post-procedural complications?

The primary factor for assigning codes related to post-procedural complications is the provider's documentation of the relationship. Accurate coding relies heavily on the provider’s notes and observations because they detail the connection between the procedure performed and any complications that arise. This documentation is essential as it provides a clear medical rationale for why a specific complication is considered related to a procedure, ensuring that the coding reflects the medical necessity and context accurately.

While time of infection onset, severity of the infection, and type of procedure performed are all relevant factors in a clinical setting, they do not take precedence over the importance of clear, specific documentation from the healthcare provider. This information is used to clarify the nature of the complication and its timing in relation to the procedure, shaping the correct coding assignment. Therefore, the provider's documentation is critical for not only identifying complications but also for justifying the coding decisions to payers or auditors.